PTSD Treatment: What Research Shows About Evidence-Based Approaches

Post-traumatic stress disorder affects approximately 7 to 8 percent of Americans at some point in their lives, with higher rates among specific populations including combat veterans, survivors of sexual assault, first responders, and survivors of natural disasters and community violence. Research on PTSD treatment has advanced substantially over the past two decades, with randomized controlled trials establishing a clear hierarchy of evidence for different approaches. Despite this progress, access to evidence-based treatment remains limited, and significant proportions of those affected by PTSD do not receive the treatments that research supports. The diagnostic criteria for PTSD specify four clusters of symptoms: intrusion, including flashbacks and nightmares; avoidance of trauma-related stimuli and memories; negative alterations in cognition and mood; and alterations in arousal and reactivity. The diagnosis requires these symptoms to persist for more than one month following exposure to a traumatic event and to cause clinically significant distress or functional impairment. Research on PTSD prevalence finds that many people who are exposed to traumatic events do not develop PTSD, and that multiple factors including social support, prior trauma history, and the nature of the traumatic event moderate the risk of PTSD development. Prolonged Exposure therapy is one of two treatments with the strongest evidence base for PTSD. Developed by Edna Foa and colleagues at the University of Pennsylvania, PE involves having clients repeatedly revisit memories of the traumatic event in a safe therapeutic context, processing the emotions that arise, and gradually confronting trauma-related situations that have been avoided. The theoretical rationale draws on emotional processing theory, which holds that traumatic memories are not processed in ways that allow normal fear extinction and that repeated exposure under safe conditions facilitates this processing. Randomized controlled trials find large effects of PE on PTSD symptom severity, with effects maintained at long-term follow-up. Cognitive Processing Therapy, developed by Patricia Resick and colleagues, is the second treatment with top-tier evidence for PTSD. CPT addresses the impact of trauma on beliefs about oneself, others, and the world, targeting what the treatment calls stuck points, meaning beliefs that maintain PTSD symptoms by promoting avoidance and distorted thinking. The treatment involves written accounts of the traumatic event, analysis of these accounts for stuck points, and structured worksheets that challenge problematic beliefs. Randomized trials find effects comparable to PE, and CPT has advantages of somewhat greater manualization that facilitates training and dissemination. Eye Movement Desensitization and Reprocessing, which involves bilateral stimulation using eye movements, taps, or tones while clients process traumatic memories, is also supported by evidence from multiple trials. The theoretical mechanism of EMDR is debated, with some researchers arguing that the eye movements themselves are not necessary and that effects are attributable to imaginal exposure to traumatic content. Whether EMDR has advantages over exposure-based therapies without bilateral stimulation in effectiveness or in its acceptability to clients who are reluctant to engage in prolonged imaginal exposure is still being studied. Medication approaches to PTSD have a more modest evidence base than trauma-focused psychotherapy. Sertraline and paroxetine are FDA-approved for PTSD, and research finds that they reduce PTSD symptoms compared to placebo, though the effect sizes are smaller than those found for trauma-focused therapies. Prazosin, an alpha-blocker medication, has been studied specifically for trauma-related nightmares and showed promise in early trials, though a large Veterans Affairs trial found null results. Research on combinations of medication and psychotherapy finds that combined approaches may benefit patients with specific presentations, particularly those with comorbid depression. Access to trauma-focused psychotherapy is limited by the shortage of trained providers. PE and CPT require substantial training and supervision to deliver with fidelity, and many mental health providers have not received this training. The VA has made substantial investments in training clinicians in PE and CPT, with research finding that trained VA providers can deliver these treatments with fidelity and that veterans who receive them show symptom improvement. Community settings, where most non-veteran PTSD treatment occurs, have less systematic training and implementation support. Technology-assisted delivery of PTSD treatment has been explored as a means of expanding access. Research on internet-delivered versions of PE and CPT finds that self-guided and therapist-guided online programs produce improvements in PTSD symptoms, with larger effects for programs that include therapist support. Mobile applications that support PTSD self-management, including apps developed by the VA, have been studied and show modest symptom improvements. These technology-based approaches may expand access for individuals who cannot access in-person treatment, though they are unlikely to fully substitute for therapist-guided care for individuals with severe symptoms. Complex PTSD, which includes the core PTSD symptoms alongside pervasive difficulties in emotion regulation, self-perception, and relationships that arise from chronic interpersonal trauma, is a diagnostic category recognized in the International Classification of Diseases but not yet in the American DSM. Research on treatment of complex PTSD is less developed than for standard PTSD, and debate about whether standard trauma-focused therapies are appropriate for this population or whether phase-based approaches that address emotion regulation first are more effective continues in the clinical literature.