Literature Review PTSD Treatment Strategies

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‭PTSD TREATMENT STRATEGIES‬ ‭1‬

‭Running Head: PTSD TREATMENT STRATEGIES‬

‭PTSD Treatment Strategies: A Review of the Literature‬

‭Cristina Pearse‬

‭Wake Forest University‬


‭PTSD TREATMENT STRATEGIES‬ ‭2‬

‭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)‬

‭significant progress in the understanding of neuroscience (neural circuitry) related to threat‬

‭response combined with molecular-genetic impacts on the individual, especially in childhood;‬

‭(b) identifying the biological implications of that knowledge toward the broader social context,‬

‭especially as this disorder is often underreported and misdiagnosed within marginalized‬

‭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

‭Literature Review on Posttraumatic Stress Disorder: Treatment Strategies‬

‭Introduction‬

‭Definition of PTSD‬

‭The American Psychological Association (APA) defines Post-Traumatic Stress Disorder‬

‭(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).‬

‭Prevalence and Significance‬

‭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

‭previous criteria were insufficiently developmentally informed (Scheeringa et al., 2011).‬


‭PTSD TREATMENT STRATEGIES‬ ‭4‬

‭Economic Burden of PTSD‬

‭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,‬

‭societal and economic burdens of PTSD (Davis et al, 2022).‬

‭Methods‬

‭The DSM-IV-TR (2022), DSM-5 (2013) and DSM-IV (1994) were compared in order to‬

‭establish the background (definition, prevalence, diagnostic criteria, comorbid disorders,‬

‭prevalence, course, familial pattern, and treatment of PTSD) (American Psychiatric Association,‬

‭2022, 2013 and 1994).‬

‭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,‬

‭prevention and emphasis on neurobiological advancements in the treatment of PTSD.‬

‭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 mentioned “childhood trauma,” “complex PTSD,” and “developmental trauma.” I‬

‭specifically excluded studies that were too focused on specific theoretical approaches since this‬

‭is a general review.‬


‭PTSD TREATMENT STRATEGIES‬ ‭5‬

‭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

‭following four categories:‬

‭1)‬ ‭Intrusive Symptoms‬‭: The individual experiences intrusive and distressing‬

‭symptoms, which may include recurrent and involuntary distressing memories,‬

‭nightmares, flashbacks, or intense psychological distress when exposed to‬

‭reminders of the traumatic event.‬

‭2)‬ ‭Avoidance and Numbing‬‭: The individual actively avoids reminders of the‬

‭traumatic event and may exhibit emotional numbness, detachment from others,‬

‭and a reduced interest in significant activities.‬

‭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

‭difficulty remembering aspects of the traumatic event.‬


‭PTSD TREATMENT STRATEGIES‬ ‭6‬

‭4)‬ ‭Arousal and Reactivity‬‭: People with PTSD may experience heightened arousal‬

‭symptoms, such as irritability, anger, difficulty sleeping, hypervigilance, and an‬

‭exaggerated startle response.‬

‭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

‭individuals, fear-based reexperiencing, emotional, and behavioral symptoms may predominate.‬

‭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

‭these symptom patterns (American Psychiatric Association, 2013).‬

‭Historic Changes to the DSM‬

‭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

‭(intrusion, avoidance, hyperarousal) to a four-cluster model (intrusion, avoidance, negative‬

‭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

‭expression of PTSD. Notably, Complex PTSD (cPTSD) is now acknowledged as a related‬

‭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

‭construct of a categorically-based construct (Watson, 2019; Auxéméry, 2011).‬

‭Current Pharmacological Treatments‬

‭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).‬

‭Current Trauma-Focused Psychotherapeutic Approaches‬

‭Currently, psychotherapeutic treatments are the gold standard treatment for PTSD‬

‭(Kirkpatrick & Heller, 2014; Larsen et al., 2023; Mitchell et al., 2023). These include‬

‭Cognitive-Behavioral Therapy (CBT), Prolonged Exposure (PE), and Cognitive Processing‬

‭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

‭& Olff, 2021; Schrader & Ross, 2021).‬

‭Other forms of therapy used in the treatment of PTSD include Group Therapy,‬

‭Mindfulness-Based therapies such as Mindfulness-Based Stress Reduction (MBSR) and‬

‭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

‭part of a holistic treatment plan (Wynn, 2015).‬

‭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

‭Diagnostic & Treatment Considerations and Controversies‬

‭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

‭disorders, thus further obfuscating the clinical picture (Auxéméry, 2011).‬

‭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

‭individual (Schrader & Ross, 2021).‬

‭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;‬

‭Magruder, McLaughlin & Elmore as cited in Bisson & Olff, 2021).‬

‭Theoretical Framework of PTSD‬

‭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

‭treatment modalities (Schrader & Ross, 2021; Mitchell et al., 2023).‬

‭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

‭the efficacy of PTSD treatment options (Russo, et al., 2023).‬

‭Future Therapeutic Directions‬

‭MDMA-assisted psychotherapy may become an option for individuals with‬

‭treatment-resistant PTSD in the future (Mitchell, et al., 2023). MDMA-assisted psychotherapy‬

‭(MDMA-AT) involves the dispensation of MDMA (3,4-methylenedioxymethamphetamine) in a‬

‭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

‭to placebo with therapy over 18 weeks (Mitchell, et al., 2023).‬

‭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,‬

‭ethnicity, severity of symptoms, historical treatment-resistance and socio-economic levels.‬

‭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

‭therapeutic efficacy (Alexander, 2012).‬

‭Discussion‬

‭Research Gaps‬

‭Further study is needed to unravel the underlying neurobiological mechanisms and‬

‭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

‭amygdala–hippocampus–prefrontal cortex circuit, which is among the most well-understood‬

‭networks in behavioral neuroscience (Auxéméry, 2011; Russo et al., 2023).‬

‭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,‬

‭psychological, behavioral, environmental) should be conducted to gain greater understanding of‬

‭observed patterns (Kirkpatrick & Heller, 2014).‬


‭PTSD TREATMENT STRATEGIES‬ ‭12‬

‭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

‭definitional issues, e.g. they need a better-differentiated, empirically-grounded view of cPTSD,‬

‭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

‭(Watson, 2019; Davis et al., 2022).‬

‭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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