Literature Review PTSD Treatment Strategies
Literature Review PTSD Treatment Strategies
Literature Review PTSD Treatment Strategies
Cristina Pearse
Abstract
Although post-traumatic stress disorder (PTSD) is one of the few mental disorders in which the
cause is readily identifiable, the individualized response to trauma can be highly variable. If
PTSD is an interaction between an individual, a traumatizing event (or events), and that
individual’s social context, untangling the complex interplay between these factors underscores
the sentiment that it does, indeed, take a village to effectively understand, diagnose and treat
PTSD. This literature review considers a broad selection of studies that indicate it might be
advantageous to shift from parsing PTSD symptomatology for classification purposes, which
itself has been highly controversial, in an effort to match individuals to their “best”
psychotherapeutic and pharmacologic treatment path toward a more holistic approach. Clinicians
know that PTSD presents many faces, and at unpredictable times. Transformational advances in
the conceptual framework for diagnosing and treating PTSD are now possible because of (a)
(b) identifying the biological implications of that knowledge toward the broader social context,
populations; and (c) recognizing that the extraordinary efficacy of emergent psychedelic-assisted
therapies in clinical trials, if they are legalized in early 2024, may significantly alter the
landscape not only for individuals who suffer PTSD symptoms, but for society at large.
.
PTSD TREATMENT STRATEGIES 3
Introduction
Definition of PTSD
(PTSD) as a psychiatric disorder that may occur in people who have experienced or witnessed a
single traumatic event, a series of events or set of circumstances that is life-threatening or poses a
serious threat. Examples of trauma events include natural disasters, serious accidents, terrorist
acts, war/combat, rape/sexual assault, historical trauma(s), intimate partner violence and extreme
bullying. Put simply: PTSD can occur in persons of any age who experience fear, helplessness,
or horror following threat of injury or death (Yehuda & LeDoux, 2007).
PTSD is a costly and serious neuropsychiatric condition affecting approximately 1 out of
20 people (or about 5-6%) in the US each year (Mitchell et al., 2023, citing the US Department
of Veterans Affairs). For military veterans, the prevalence of PTSD could be as high as 30% for
Vietnam-era veterans or 13-14% for veterans of recent, more brief wars; Rates of PTSD are
higher for individuals whose vocation increases the risk of traumatic exposure, e.g., police,
firefighters, and emergency rescue and/or medical personnel (Schrader & Ross, 2021).
Approximately 6.8% of persons in the United States develop PTSD at some point during their
lives (Kessler et al., 2005 cited by Yehuda & LeDoux, 2007). On the other hand, children and
adolescents, including preschool children, generally have displayed lower prevalence following
exposure to serious traumatic events. However, this lower prevalence might only be because
The total excess economic burden of PTSD in the US was estimated at $232.2 billion for
2018 (Davis, et al., 2022). Increased awareness of PTSD, development of more effective
therapies, and expansion of evidence-based interventions could reduce the immense individual,
Methods
The DSM-IV-TR (2022), DSM-5 (2013) and DSM-IV (1994) were compared in order to
prevalence, course, familial pattern, and treatment of PTSD) (American Psychiatric Association,
I accessed two databases, APA PsycInfo and PubMed, through the Wake Forest
University Z. Smith Reynolds (ZSR) library using date parameters of 2009 - present for search
terms used “PTSD,” “trauma,” “posttraumatic stress disorder,” and “stress disorders.” This
yielded hundreds of results for which I then filtered the results by date (preferring most recent). I
then selected a sampling of studies that would yield a cross-section of treatment options,
Finally, and to reflect the latest updates to the DSM which include developmental and
childhood trauma, or Complex PTSD as a related topic to PTSD, I looked for studies that
specifically excluded studies that were too focused on specific theoretical approaches since this
Results
Diagnosis
The diagnosis of PTSD is based on specific criteria outlined in the Diagnostic and
Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), which is published by the APA
(American Psychiatric Association, 2013): An individual must have had exposure to a traumatic
event, either through direct experience, witnessing it happen to others, learning that a close
friend or family member experienced the event, or being repeatedly exposed to distressing details
of the traumatic incident. Then, the individual may exhibit symptoms from one or more of the
2) Avoidance and Numbing: The individual actively avoids reminders of the
traumatic event and may exhibit emotional numbness, detachment from others,
3) Negative Changes in Cognition and Mood: Individuals with PTSD may have
persistent negative thoughts or beliefs about themselves, others, or the world, and
they may experience distorted blame or guilt. They might also have persistent and
exaggerated negative emotions (e.g., fear, horror, anger, guilt) and a diminished
interest in activities they previously enjoyed. In some cases, there may be
4) Arousal and Reactivity: People with PTSD may experience heightened arousal
For a formal diagnosis of PTSD, these symptoms must persist for more than a month and
cause significant distress or impairment in the individual's daily life. PTSD can be a debilitating
condition that requires proper diagnosis and appropriate treatment to help individuals recover
and manage their symptoms effectively. The clinical presentation of PTSD varies. In some
In others, anhedonic or dysphoric mood states and negative cognitions may be most distressing.
In some other individuals, arousal and reactive-externalizing symptoms are prominent, while in
others, dissociative symptoms predominate. Finally, some individuals exhibit combinations of
The diagnostic criteria for PTSD has been revised in the current DSM-5 (American
Psychiatric Association, 2013). In the latest version it expands from a three-cluster model
alterations in cognition and mood, arousal). It also now includes more explicit examples of
qualifying events to include direct and indirect exposure to traumatic events. When cases met
criteria for DSM-IV, but not DSM-5, this was primarily due to the revision excluding sudden
unexpected death of a loved one from Criterion A in the DSM-5. The other reason was a failure
to have a minimum of one avoidance symptom. When cases met criteria for DSM-5, but not
DSM-IV, this was primarily due to not meeting DSM-IV avoidance/numbing and/or arousal
criteria. Research also suggests that similarly to DSM-IV, prevalence of PTSD for DSM-5 was
PTSD TREATMENT STRATEGIES 7
higher among women than men and increased with multiple traumatic event exposure (such as
sexual abuse). The DSM-5-TR updates include summarizations of cultural factors, such as type
of traumatic exposure or sociocultural context, that may influence the development and clinical
condition which may develop in certain individuals exposed to chronic trauma, often in
childhood.
As the medical community further refines how to categorize and classify PTSD, it is also
noteworthy that there is significant research supporting that PTSD is the consequence of
epidemiological, psychopathological and neurogenetic forces which might not fit within the tidy
Although the selective serotonin reuptake inhibitors (SSRIs) sertraline and paroxetine are
FDA approved for treating PTSD, 35–47% of individuals do not respond to treatment. Some may
even be harmed by side effects of these medications (Alexander, 2012; Mitchell et al., 2023).
Currently, psychotherapeutic treatments are the gold standard treatment for PTSD
(Kirkpatrick & Heller, 2014; Larsen et al., 2023; Mitchell et al., 2023). These include
Therapy (CPT)(Schrader & Ross, 2021; Larsen et al., 2023). However, engagement in
trauma-focused psychotherapy is difficult for some patients with PTSD, especially those with
extreme affect dysregulation associated with recall of traumatic memories (Scheeringa et al,
2011). Eye Movement Desensitization and Reprocessing (EMDR), a specialized form of
psychotherapy that incorporates guided eye movements or other forms of bilateral stimulation,
PTSD TREATMENT STRATEGIES 8
can help some individuals process traumatic memories to reduce their emotional impact (Bisson
Other forms of therapy used in the treatment of PTSD include Group Therapy,
Mindfulness-Based Cognitive Therapy (MBCT)(Wynn, 2015). Some individuals find relief from
PTSD symptoms through complementary approaches like acupuncture, yoga, and meditation.
Animal-assisted activities (AAT) or service animals and recreational therapy can also be used as
More effective, evidence-based treatments are needed to adequately treat the individual,
societal and economic burdens of PTSD (Mitchell, et al., 2023). Very little research has been
conducted on patients’ actual experiences with treatment decision-making (Larsen et al., 2023).
Discussion
In the US, when PTSD affects racial and ethnic minorities, it is usually untreated
(Roberts et al., 2011). Large disparities in diagnosis and treatment indicate the need for
investment in accessible and culturally sensitive treatment options. Potential reasons for these
prevalence variations include differences in predisposing or enabling factors, such as exposure to
past adversity and racism and discrimination, and in availability or quality of treatment, social
support, socioeconomic status, and other social resources that facilitate recovery and are
confounded with ethnic and racialized background (Davis et al., 2022; Gagnon-Sanschagrin et
al., 2022).
The risk of developing PTSD after severe trauma depends on multiple factors and can
also include genetics. For example, at least 30–40% of the risk of PTSD is heritable (Ressler et
PTSD TREATMENT STRATEGIES 9
al., 2022). If the trauma (or series of traumas) occurs early in development, a form of chronic
PTSD can appear as other comorbid disorders such as mood disorders, alcohol, or substance use
Although there are effective PTSD treatments, the number of patients who receive them
is disappointingly low (Shiner et al., 2022; Maguen et al., 2018; Finley et al., 2015, as cited by
Larsen et al., 2023). In one study between 2015 and 2019 of 1,515, 354 patients with a diagnosis
of PTSD, only 4.1% received a nominal course of therapeutic treatment (Larsen et al., 2023).
One challenge is matching individuals with the therapeutic path that works best for that
The COVID-19 crisis was a timely reminder that traumatic experiences take all forms
and are highly prevalent across the world and a major public health issue (Kessler et al;
Advancements in both research and clinical practice have drastically altered the
landscape of PTSD treatment (Schrader & Ross, 2021). Now, more than ever, the standard of
care provides more effective, personalized, and evidence-based care for individuals struggling
with the negative effects of trauma. Technological advancements such as virtual reality therapy,
combination therapies that expand beyond symptom reduction, and novel treatments such as the
integration of substances such as MDMA in the therapeutic context all hold promise as viable
By combining (a) molecular–genetic scientific approaches with (b) knowledge of
neurological fear circuitry, transformative advances in the conceptual framework, diagnosis and
PTSD TREATMENT STRATEGIES 10
treatment of PTSD are now possible. An integrated approach holds promise to greatly improve
controlled therapeutic setting in order to enhance the therapeutic process, and, ultimately, reduce
the symptoms of PTSD. MDMA-AT shows significant promise as a treatment option, especially
for treatment-resistant individuals (Krystal, 2021; Mitchell, et al., 2023). In an FDA phase 3 trial,
the participants (with moderate to severe PTSD) experienced significantly improved PTSD
symptoms and functional impairment, as assessed by CAPS-5 and SDS, respectively, compared
In these trials, manualized therapy was combined with MDMA with some modification
and refinement over the course of these trials. Notably, in the third trial, nearly 87% of the
participants treated with MDMA-AT reported the easing of PTSD symptoms; 71.2% of the
participants no longer met criteria for PTSD by study end. Also equally significant is that
participants who identified as ethnically or racially diverse encompassed approximately half of
the study sample (Mitchell et al., 2023). In short, MDMA-AT is clinically significant across race,
As of today, MDMA is still classified as a Schedule I controlled substance in the US.
Australia legalized MDMA for therapeutic use. However, MDMA for therapeutic use may be
approved in the US as a prescription medication in early 2024 (Mitchell et al, 2023). MDMA is
PTSD TREATMENT STRATEGIES 11
one of several so-called psychedelic compounds (psilocybin, DMT5, LSD, etc.) being tested for
Discussion
Research Gaps
implications on trauma and brain function. Many of the neural circuit mechanisms that underlie
the PTSD symptoms of fear-related and threat-related behavior, hyperarousal and sleep
dysregulation are becoming increasingly clear. Key brain regions involved in PTSD include the
Improved diagnosis, particularly when comorbid with other disorders, could help identify
latent forms of PTSD, and perhaps simplify the diagnostic process for childhood trauma and
cPTSD. Also, improved screening protocols, such as broadly implementing Adverse Childhood
Events, or ACEs, screening and other diagnostic tools may inform clinicians and administrators
how to detect and treat cPTSD in children at its earliest stages (Russo et al., 2023).
Understanding whether PTSD symptoms to one event may exacerbate the reaction to a
subsequent event and/or conversely, the experience of a new event may reactivate or worsen
symptoms to a previously experienced event(s) could add to knowledge regarding the impact of
cumulative exposure to events (Grasso et al., 2009). Such information might also be relevant to
explore within treatment approaches that may need to more clearly address symptoms that relate
to more than one traumatic event. Further study of potential underlying mechanisms (biological,
Other issues that need more research stem from general observations that the clinical
expression of PTSD symptoms can vary across lifespan development; Clinicians cannot yet
predict when someone might develop cPTSD or PTSD; Clinicians must navigate comorbid and
PTSD, BPD, and other comorbidities for the advancement of clinical practice and research with
traumatized children and adults (Ford, 2020; Grasso et al., 2009); More studies are needed to
determine whether there are neurobiological markers for PTSD and trauma (Yehuda & LeDoux,
2007; Auxéméry, 2011); and additional resources are needed to identify the overall trends in
trauma exposure that go largely untreated, yet exact a tremendous burden on our society
Since PTSD is one of the few mental disorders in which the cause is readily identifiable,
there is considerable hope for the improved diagnosis and treatment of PTSD. It might take a
village to embrace the concept of PTSD as a systemic disorder that impacts all of society if left
untreated. However, highly effective therapies appear on the horizon with the promise of
addressing the root cause of trauma (Mitchell et al, 2023; Bisson & Olff, 2021; Krystal, 2021).
PTSD TREATMENT STRATEGIES 13
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