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Agency for Healthcare Research and Quality (US), Rockville (MD)
Forman-Hoffman V, Middleton JC, Feltner C, et al. Psychological and Pharmacological Treatments for Adults With Posttraumatic Stress Disorder: A Systematic Review Update [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2018 May. (Comparative Effectiveness Review, No. 207.) Appendix A, Intervention Descriptions.
| Intervention | Description |
|---|---|
| Cognitive behavioral therapy (CBT) | Uses principles of learning and conditioning to treat PTSD via individual or group therapy. It includes components from both behavioral and cognitive therapy. The therapist may use one or more components of CBT, including exposure, cognitive restructuring, and various coping skills to treat patients with PTSD. Most forms of CBT consist of a minimum of 8 to 12 weekly sessions lasting 60 to 90 minutes.105, 108, 195, 196 |
| Cognitive interventions | Includes cognitive processing therapy (CPT), cognitive therapy (CT), and cognitive restructuring (CR). The theory behind cognitive interventions suggests that the interpretation of life events, rather than the event itself, determines an individual’s mood. It aims to facilitate relearning thoughts and beliefs generated from a traumatic event, increase awareness of dysfunctional trauma-related thoughts, and correct or replace those thoughts with more adaptive or rational cognitions.105, 108 |
| Coping skills therapy | Includes stress inoculation therapy (SIT), structured approach therapy, and relaxation training. All may use techniques such as education, muscle relaxation training, breathing retraining, and role playing to manage anxiety or correct misunderstandings conditioned at the time of trauma. The therapy is designed to increase coping skills for current situations. Most types of coping skills therapies require at least eight 60- to 90-minute sessions, while; more comprehensive interventions such as stress inoculation therapy require 10 to 14 sessions.105, 108 |
| Exposure-based therapy | Involves confronting feared stimuli to extinguish the conditioned emotional response (usually anxiety) to traumatic stimuli. The therapist helps the client use mental imagery from memory or introduces hypothetical “scenes” of the traumatic event to the client (imaginal exposure). In some cases, the therapist uses an actual scene or similar events in life as the exposure (in vivo exposure).101, 105, 108 |
| Eye movement desensitization and reprocessing (EMDR) | Combines imaginal exposure (described above) with the concurrent induction of rapid, intermittent eye movements believed to help reprogram brain function to resolve the emotional impact of trauma. In the EMDR process, the therapist instructs the patient to imagine a traumatic memory, engage in negative cognition, and articulate an incompatible positive cognition (e.g., personal worth). The therapist asks the patient to contemplate memory while focusing on rapid movement of the therapist’s fingers. After 10 to 12 eye movements (back and forth), the therapist asks the patient to rate the strength of the memory and his or her belief in the positive cognition. Although earlier versions of EMDR consisted of one to three sessions, current standards consist of 8 to 12 90-minute weekly sessions.108, 195 |
| Interpersonal therapy (IPT) | A time-limited, psychodynamic therapy that aims to alleviate patients’ suffering and improve their interpersonal functioning. The premise of psychodynamic therapies assumes that PTSD symptoms result from unconscious memories, that the process of moving the memories into conscious awareness can allow the therapist to help the client work through thoughts about the memories. This type of therapy focuses specifically on interpersonal relationships and aims to help patients either improve their interpersonal relationships and social support, in part by changing their expectations about them.197 |
| Trauma affect regulation (TAR)a | A manualized intervention designed to enhance the ability to anticipate and prevent or recover from (by regaining emotional equilibrium) the rapid acceleration of emotional distress associated with traumatic victimization.59 |
| Narrative exposure therapy (NET) | A standardized, short-term treatment based on adapting CBT exposure therapy to meet the unique needs of those exposed to war and torture.161 |
| Brief eclectic psychotherapy (BEP) | A manualized intervention that combines cognitive-behavioral and psychodynamic approaches for treating patients with PTSD. Eclectic psychotherapy uses techniques drawn from several different theoretical orientations. It allows flexibility in the approach the therapist uses in working with a patient to adapt to that individual’s needs, rather than approaching the patient and his/her issues from a specific psychological orientation. Some therapists adhere largely to a single orientation, such as psychoanalysis or CBT but use eclectic techniques as needed. Other therapists self-identify as eclectic in orientation, using whichever techniques work best in any given situation. Number and length of sessions vary widely. |
| Imagery rehearsal therapy (IRT) | A therapy based on cognitive-behavioral “cognitive-behavioral technique” based on the notion that “waking activity can influence the content of night-time dreams.”156 IRT therapy targets trauma-related nightmares and, by doing so, attempts to reduce the severity of PTSD and improve the quality of sleep. |
| Memory specificity training (MEST) | A manualized treatment focused on decreasing faulty overgeneralization of memories. The goal is to improve problem solving and executive control by learning how to decrease cognitive avoidance and rumination. MEST can be performed using a 6 session (weekly) model or a 12 session biweekly model. Typically, sessions are 90 minutes in length. |
| Hypnosis | A technique for evoking a state of concentration that increases openness and ability to respond to suggestion and make changes to thoughts and behaviors. Often times used as an adjunct to other therapies and; it has been shown to significantly enhance efficacy of other treatments for many clinical conditions. Numbers and lengths of sessions vary widely. |
| Energy psychology including emotional freedom techniques (EFT) | A holistic method focused on the mind-body connectedness of thoughts, behaviors, sensations, and emotions. Techniques access energy systems via chakra techniques, biofield practices, and meridian interventions while administering psychological treatment. A related treatment, referred to as emotional freedom techniques (EFT), taps various energy points on the skin while focusing on various situations that evoke strong feeling, thoughts, or emotions to shift neurological pathways that facilitate improvements to psychological functioning. |
| Mindfulness based stress reduction (MBSR) | MBSR is a treatment that uses meditation to increase awareness of present mental and physical processes. The instructor leads participants through meditative exercises that focus on noticing sensations, thoughts, and emotions without judgment, and the participants practice short guided meditation exercises outside of sessions. Can be administered individually or in a group setting. |
| Neurofeedback training (NF) | NF is a type of biofeedback therapy where subjects respond to a display of their own brainwaves or other electrical activity of the nervous system to teach self-regulation of brain function in an effort to increase its efficiency. Sessions typically are administered over the course of several months. |
Full name: Trauma Affect Regulation: Guide for Education and Therapy (TARGET)
| Class | Drug |
|---|---|
| SSRIs | Citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, and sertraline |
| SNRIs | Desvenlafaxine, venlafaxine, and duloxetine |
| TCAs | Imipramine, amitriptyline, and desipramine |
| Other second-generation antidepressants | Bupropion, mirtazapine, nefazodone, and trazodone |
| Alpha blockers | Prazosin |
| Second-generation (atypical) antipsychotics | Olanzapine, risperidone, ziprasidone, aripiprazole and quetiapine |
| Anticonvulsants (mood stabilizers) | Topiramate, tiagabine, lamotrigine, carbamazepine, and divalproex |
| Benzodiazepines | Alprazolam, diazepam, lorazepam, and clonazepam |
| Other medications | Naltrexone, cycloserine, and inositol |
PTSD = posttraumatic stress disorder; SNRI = serotonin and norepinephrine reuptake inhibitors; SSRI = selective serotonin reuptake inhibitor; TCA = tricyclic antidepressant.