Posttraumatic Stress Disorder (PTSD) Treatment

Posttraumatic stress disorder (PTSD) is a complex condition characterized by recurrent, intrusive memories, distressing dreams, flashbacks, and/or severe anxiety about a terrifying event you experienced or witnessed. This might be anything from a serious car accident to a terrorist attack to a natural disaster to a physical assault.

Maybe you avoid thinking or talking about what happened. Maybe you avoid the people, places, and activities associated with the event.

Maybe you think it’s all your fault. Maybe you feel so much shame. Maybe you think no one can be trusted. Maybe you think the world is an awful place.

Maybe you also have a hard time falling asleep or staying asleep. Maybe you’re easily startled, and feel like you’re constantly on guard and on edge. Maybe you also feel hopeless about the future, and like things will never change.

Thankfully, there’s help for PTSD. Real, research-supported help.

The best treatment for PTSD is evidence-based psychotherapy, which includes trauma-focused cognitive behavioral therapy and eye movement desensitization and reprocessing (EMDR).

Medications also can be helpful. But in general treatment guidelines from various associations suggest that medication shouldn’t be offered as a first-line treatment (therapy should).

According to guidelines from the Australian Centre for Posttraumatic Mental Health, medication can be helpful when you’re not getting enough benefit from psychotherapy; you don’t want to attend therapy or it’s not available; or you have a co-occurring condition that can benefit from medication (such as depression).

Psychotherapy

The American Psychological Association (APA) treatment guidelines for PTSD, along with other guidelines, recommend the below evidence-based therapies. Each one is a type of cognitive behavioral therapy (CBT).

• Trauma-focused cognitive behavioral therapy (CBT) includes challenging and changing automatic unhelpful, inaccurate thoughts (called cognitive distortions) about the trauma, such as: It was all my fault that I got mugged. I shouldn’t have been in that neighborhood. I should’ve seen that IED, and because I didn’t, they died. If I hadn’t been drinking, I would’ve been able to escape. CBT also involves gradually and safely being exposed to the trauma. This might include describing the traumatic event and writing about it (“imaginal exposure”), and/or visiting places that remind you of the event (“in vivo exposure”). For instance, you might visit the street of your car accident. In the short term, avoiding feelings, thoughts, and situations related to your trauma eases your anxiety, but in the long term, it only feeds the fear, and narrows your life.
• Cognitive processing therapy (CPT) focuses on challenging and changing upsetting thoughts that perpetuate your trauma. CPT typically includes writing a detailed account of the trauma and reading it in front of your therapist and at home. The therapist helps you challenge problematic beliefs around safety, trust, control, and intimacy.
• Cognitive therapy (CT) helps you challenge and reframe your pessimistic thoughts and negative interpretation of the traumatic event. Your therapist will help you work through ruminating about the trauma and suppressing your thoughts (most people try not to think about what happened, which only exacerbates PTSD symptoms; the more we resist thinking certain thoughts, the more they persist and go unprocessed).
• Prolonged exposure (PE) involves safely and gradually processing the trauma by discussing the details of what happened. As you recount the event, the therapist will record it, so you can listen at home. Over time, this reduces your anxiety. PE also involves facing situations, activities, or places that you’ve been avoiding which remind you of your trauma. Again, this is done slowly, safely, and systematically. Plus, you learn breathing techniques to alleviate your anxiety during exposure.

The APA also suggests these three therapies, which research has found to be helpful in treating PTSD (though there might be less research when compared to trauma-focused CBT):

• Eye movement desensitization and reprocessing (EMDR) involves imagining the trauma while the therapist asks you to track their fingers as they move them back and forth in your field of vision. If storing memories is like putting away groceries, a traumatic event was stored by shoving a bunch of stuff in a cabinet and then any time it gets opened all the stuff falls on your head. EMDR allows you to pull everything out in a controlled manner and then put it away in the organized way that non-traumatic memories are stored. Unlike CBT, EMDR doesn’t require you to describe the traumatic memories in detail, spend an extended time on exposure, challenge specific beliefs, or complete assignments outside of therapy sessions.
• Brief eclectic psychotherapy (BEP) combines CBT with psychodynamic psychotherapy. The therapist will ask you to discuss the traumatic event, and teach you various relaxation techniques to decrease your anxiety. The therapist also helps you explore how the trauma has affected how you see yourself and your world. And you’re encouraged to bring someone who supports you to some of your sessions.
• Narrative exposure therapy (NET) helps you create a chronological narrative of your life, which includes your traumatic experiences. NET helps you recreate an account of the trauma in a way that recaptures your self-respect and recognizes your human rights. At the end of treatment, you receive your documented biography written by your therapist. NET is typically done in small groups, and with individuals struggling with complex trauma or multiple traumatic experiences, such as refugees.

To get a better idea of what these treatments actually look like in session with a therapist, visit the APA’s website to read different case studies.

As with any therapy, finding a therapist that you feel comfortable with and can trust is critical. If possible, start by interviewing several therapists about the treatment approaches they use for trauma.

The therapist you pick should be clear with you about what your treatment plan is, and address any concerns that you have about your symptoms and your recovery.

With the right therapist, you will be able to work on your trauma, and they should be flexible enough to shift your treatment plan if things aren’t working. If you’re finding that the therapist isn’t a good fit for you, consider finding a different clinician.

Medications

Again, therapy appears to be the best initial (and overall) treatment for PTSD. But if you’d like to take medication, guidelines from the American Psychological Association, along with other associations, recommend prescribing selective serotonin reuptake inhibitors (SSRIs), including fluoxetine (Prozac), paroxetine (Paxil) and sertraline (Zoloft), and the selective serotonin and norepinephrine reuptake inhibitor (SNRI) venlafaxine (Effexor).

These medications appear to have the strongest evidence in reducing PTSD symptoms along with being the most tolerable.

Still, SSRIs and SNRIs do come with bothersome side effects, such as sexual dysfunction (e.g., decreased sexual desire, delayed orgasm), drowsiness or fatigue, nausea, diarrhea, and excessive sweating.

It’s important not to abruptly stop taking your medication, because doing so can lead to discontinuation syndrome. Essentially, this is a variety of withdrawal symptoms, such as dizziness, insomnia, and flu-like symptoms. Instead, discuss your desire to stop taking the medication with your doctor, who will help you taper off the SSRI or SNRI slowly and gradually. And even then, withdrawal symptoms can still occur.

It generally takes about 6 to 8 weeks for an SSRI or SNRI to work (and longer to experience the full benefits). Many people don’t respond to the first medication they take. When this happens, your doctor will likely prescribe a different SSRI or venlafaxine.

Guidelines from the National Institute for Health and Care Excellence (NICE) note that antipsychotic medication might be helpful for individuals who have disabling symptoms and haven’t responded to SSRIs (or venlafaxine) or therapy, or are unable to engage in therapy. Similarly, guidelines from the Australian Centre for Posttraumatic Mental Health suggest prescribing risperidone (Risperdal) or olanzapine (Zyprexa) as an adjunctive medication.

However, the APA notes that there’s insufficient evidence to recommend for or against risperidone. (They didn’t mention any other atypical antipsychotic medication.)

Atypical antipsychotic medication can have significant side effects, including sedation, weight gain, an increase in glucose and lipid levels, and extrapyramidal symptoms. The latter can include tremors, muscle spasms, slower movement, and uncontrollable facial movements (e.g., sticking out your tongue, repeatedly blinking).

Guidelines from the Australian Centre for Posttraumatic Mental Health also suggest prazosin (Minipress) as an adjunctive medication. Prazosin is an alpha blocker and typically treats high blood pressure. The research on prazosin has been mixed. UpToDate.com notes that in their experience, prazosin appears to reduce PTSD symptoms, nightmares, and sleep problems in some people. They also suggest prazosin as an adjunct to an SSRI or SNRI (or on its own).

Common side effects of prazosin include dizziness, drowsiness, headache, nausea, decreased energy, and heart palpitations.

Benzodiazepines are often prescribed to treat anxiety, and might be prescribed for PTSD. However, they haven’t been well-studied in PTSD; there’s some evidence that they might interfere with therapy; and other guidelines, including NICE and UpToDate.com, advise against prescribing them.

Before taking medication, make sure you bring up any concerns or questions you have to your doctor. Ask about side effects and discontinuation syndrome (for SSRIs and venlafaxine). Ask your doctor when you should expect to feel better, and what this might look like. Remember that this is a collaborative decision between you and your doctor, and one you should feel comfortable making.

If you’re taking medication, it’s also important to participate in therapy. While medications may treat some of the symptoms commonly associated with PTSD, they won’t take away the flashbacks or feelings associated with the original trauma. If you’re working with your primary care physician, ask for a referral to a therapist who specializes in treating PTSD with the interventions mentioned in the psychotherapy section.

Self-Help Strategies for PTSD

Exercise. According to guidelines from the Australian Centre for Posttraumatic Mental Health, exercise may help with sleep disturbance and somatic symptoms associated with PTSD. There are so many physical activities to choose from—walking, biking, dancing, swimming, taking fitness classes, playing sports. Pick activities that are enjoyable for you.

Consider acupuncture. Some research suggests that acupuncture may be a helpful complementary treatment for alleviating anxiety associated with PTSD. For instance, this study found that acupuncture might reduce physical and emotional pain in people who’d been through an earthquake.

Practice yoga. Research (like this interview on LifeHelper and with these audio and video practices.

It also might help to experiment with different types of yoga (and teachers) to see what feels best for you. For example, here’s a yoga practice created for individuals with trauma (which hasn’t been studied).

Work through workbooks. When navigating PTSD, it’s best to work with a therapist who specializes in the disorder. You might ask your therapist for book recommendations.

If you’re not currently working with a practitioner, these workbooks might be helpful: The Complex PTSD Workbook; The PTSD Workbook; Behavioral Activation Workbook for PTSD, A Workbook for Men; and The Cognitive Behavioral Coping Skills Workbook for PTSD.

Also, while not a workbook, the book The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma may be informative on how trauma affects our bodies.

Seek support. When you’re struggling with trauma, you can easily feel alone, especially if you’re experiencing shame (which thrives in secrecy and isolation). Support groups not only remind you that you’re not alone, they help you to connect and cultivate your coping skills. You might seek support online or in person.

For instance, LifeHelper has an online forum for PTSD.  You can call your local NAMI chapter to see what support groups they offer. The AboutFace website features stories from veterans who’ve experienced PTSD, their loved ones, and VA therapists.

In general, the Sidran Institute features a comprehensive list of trauma-related hotlines.