science of Medicine | feature review

A Review of PTSD and

Current Treatment Strategies
by Christian Schrader, MD & Abigail Ross, MS

Approximately 6-7% Abstract through use of judgement.1 Much

of the adult population Current treatment strategies of his early work focused on the
in the United States will for control of trauma-associated traumatic shocks that his patients
at some point during symptoms of Post Traumatic had endured through their lifetime;
their lifetime meet the Stress Disorder (PTSD) have many of them through workplace
criteria for a diagnosis recently been updated by the accidents, loss of life or loved ones,
of Post Traumatic Stress Veterans Affairs (VA) and the involvement in war, and from
Disorder. Department of Defense (DoD, sexual assault. Despite the efforts
after over a decade of dedicated and work of many before and
research. The most recent after him, those same traumatic
evidence is compelling that its experiences have historically elicited
use of trauma-focused therapies very similar reactions from those
such as Cognitive Processing who have suffered through them
Therapy (CPT), Prolonged and have so far, been difficult
Exposure Therapy (PE), Eye to appropriately treat. What we
Movement, Desensitization, have known for some time is that
and Restructuring (EMDR), trauma is no respecter of persons,
and others with significant status, or intellectual capacity, and
trauma focus are the current that the after effects of trauma can
gold standard for treatment. significantly impair function in life.
Additional medication use may
be of assistance in treatment The Modern Concept
of symptomology, with special of Post-Traumatic
avoidance of benzodiazepines Stress Disorder
or other sedative hypnotic The diagnosis of what is now
medications which are causal accepted as Post Traumatic Stress
of increased intrusive and Disorder (PTSD) has changed
dissociative symptoms over time. over the years as we have gained a
better understanding of the stress
Introduction response and its longer-term impact
In his early theories of the on the body and the brain. During
mind, Sigmund Freud hypothesized the Seven Years War (1756-1763)
that the individual has stages of a physician from Austria, one
psychological development: that Joseph Auenbrugger, observed and
Christian Schrader, MD, is at Carl
R. Darnall Army Medical Center
of forming an unconscious defense documented symptoms in some
Psychiatry Residency, Fort Hood, Texas. against pain and shock through troops such as excessive physical
Abigail Ross, MS, is at the New York the turning away from the triggers exhaustion, anger, and irritability
Institute of Technology College of
Osteopathic Medicine, Old Westbury, of unpleasure and finally the (angst), and depressed mood. He
New York. conscious disapproval of an impulse termed the condition “nostalgia”

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The diagnosis of what is now accepted as Post Traumatic Stress Disorder (PTSD) has changed over the years as we have
gained a better understanding of the stress response and its longer-term impact on the body and the brain.

after the soldiers being so homesick, and so far distant shared a history of documentation of similar symptoms
from that which they knew, that their personality and among their returning troops.
the core of who they were was significantly changed. In While war and violent conflict among nations may
his 1761 book Inventum Novem he wrote: be historically well documented as a cause of profound
“When young men who are still growing are forced to emotional changes, it is by sheer number alone the
enter military service and thus lose all hope of returning civilian population that will carry the numerical
safe and sound to their beloved homeland, they become burden of PTSD. By far the most common causes in
triggering traumatic events among the entire populace
sad, taciturn, listless, solitary, musing, full of sighs, and
are motor vehicle collisions and assault (inclusive of
moans. Finally, these cease to pay attention and become
sexual assault and rape). These trauma experiences are
indifferent to everything, which the maintenance of life
fairly common in childhood, with adolescents between
requires of them. Neither medicaments, nor arguments, the ages of 14-17 having a 28% lifetime prevalence
nor promises, nor threats of punishment are able to of sexual victimization with 8% of girls in that age
produce any improvement.” 2 cohort with a history of an attempted or completed
Granted, the pharmacopeia of that generation was rape against them.3 Approximately 6-7% of the adult
severely limited, ineffective for treatment of PTSD as population in the United States will at some point
it often included laudanum, strong spirits (such as rum during their lifetime, meet the criteria for a diagnosis of
and whiskey), and certain tinctures that were thought PTSD.4 Amongst the U.S. military veteran population
to improve the mood such as that of Saint Johns Wort, the variance in studies has ranged from approximately
as well as other mild sedatives such as Chamomile and 30% of the Vietnam era veterans to more recently 13-
Valerian root. His observations though were valid, and 14% of veterans serving in the dual wars in Iraq and
matched those of the Greeks and Romans who also Afghanistan over the last 20 years.5,6

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We also recognize that the self reporting of Disorders (DSM) – V and shifted from an anxiety
symptoms from these populations over the most recent disorder and into a new category of trauma associated
conflicts is under represented due to fears of stigma disorders. This was in part done to provide an updated
and concerns over job loss, just as is speculated are diagnosis representing the underlying pathology of
the numbers from the general populace, who face the illness and to further differentiate it from anxiety
the additional hurdle of potential lack of appropriate and depressive disorders which it does share some
insurance coverage for appropriate albeit specialized symptomatology with. At present, to have a diagnosis
treatments. Our primary care physicians are indeed ‘in of PTSD a person must have had a significant trauma
the trenches’ so to speak when addressing mental health exposure that has caused significant impairment to
concerns of this same populace. Among the general occupational and social function for greater than one
population in 2010 approximately 20% of all primary month.
care visits included treatment for mental health issues Symptoms must include one intrusive (recurrent,
or diagnoses - making the primary care settings an involuntary, distressing memories and/or dreams,
important place to screen for and initiate mental health dissociative reactions such as flashbacks, intense or
care.7 As all providers become more familiar with the prolonged psychological distress to triggers, or marked
diagnosis of PTSD and the current successful treatment physiological reactions to triggers); one avoidance
options, educational barriers to initiation of care symptom (avoidance of memories, feelings, or
becomes less problematic – and those we serve can start thoughts of trauma or avoidance of external reminders
care immediately while waiting on their referral to a of trauma); two negative alterations to cognition
mental health professional for continued care. or mood related to the trauma (dissociate amnesia,
Over the last two decades a wealth of research has negative beliefs of self or the world, persistent negative
been conducted on PTSD, driven primarily by the emotional state, anhedonia, feelings of detachment
rising suicide completion rates and daily impairment to or estrangement from others, inability to experience
military members with that diagnosis. Funded mainly positive emotions); two symptoms of marked
by the U.S. Governmental agencies these projects over alterations in arousal and reactivity (irritability or
the years have added to the medical knowledge and anger outbursts, reckless or self-destructive behaviors,
understanding of the brain, human behavior, the effects hyper vigilance, exaggerated startle response, problems
of persistent stress on the hypothylamic-pituitary- with concentration, sleep disturbance). A provider
adrenal axis system, stress change to the limbic- may specify if there are persistent dissociative
amygdylar circuitry, as well as more effective treatment symptoms such as depersonalization (feeling detached
strategies. Past well thought of treatments have either from oneself, as if observing from out of body)
passed the rigorous tests of double blind and placebo- or derealization (feelings of the unreality of the
controlled studies and continue in use, or did not environment). Because of the prevalence of childhood
– and have been discounted. The amount of research trauma and differences in the brain and personality
was a boon to the mental health community, who at development of children at that age, specific criteria
the time of late 1990s had only 15 controlled trials on for children ages 6 and younger are also detailed in the
treatment for PTSD to draw from.8 DSM-V.9
The following decade brought great gains. A large
meta-analysis in 2013 reviewed all available research Non-Pharmacologic Treatment for PTSD
on efficacy of treatments and interventions for PTSD,
with a total of 112 non-duplicate studies included. Shared Decision Making and Collaborative Care
This existing body of research was influential in the (Strong Recommendation for)
formation and updates to the VA and DoD clinical Both are important early interventions which
practice guidelines for assessment and treatment of have been shown to improve patient-centered care and
PTSD in that same year. treatment outcomes. Review of the relevant diagnosis
along with treatment options with consistent use of
Diagnosis decision aids with patients has been shown to improve
In 2013 the diagnosis itself received an update clinical outcomes, enhance psychoeducation on the
with the Diagnostic and Statistical Manual of Mental diagnosis of PTSD, and reduce ambivalence in regards

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to accepting the most efficacious treatment strategies.10 structure therapy with a patient has been shown in the
In particular for the collaborative care model (inclusive above, and many more studies to improve outcomes
of telehealth modalities to improve access), a stepwise – both in terms of adherence to and attendance in
treatment approach in the primary care setting has the treatment program, and in improved symptom
been shown to increase patient compliance with reduction over time as compared to therapy that does
treatment and to potentially reduce the possibility of not use a manualized approach. It in no way limits the
the patient stopping medication or therapy treatment therapist or reduces their expertise—in fact it has been
too early.11 shown to enhance it by providing a scaffolding that
addresses all core issues of trauma is a systematic way,
Trauma-Focused Therapy as First Line Treatment and provides for evidence-based work for the patient
for PTSD (Strong Recommendation for) in treatment outside of the treatment sessions. Of the
Prior to 2013 there was little evidence to suggest newer researched therapies, written exposure therapy
that there is a differentiation in treatment with has been showing excellent benefit with good treatment
pharmacotherapy versus psychotherapy. One of retention. Especially for people whose learning style
the larger changes to the updated clinical practice may be more tactile or experiential, it allows for the
guidelines was to recommend therapy over medication patient’s written narrative with additional cognitive
for treatment of PTSD, to the recommendation therapy to be the mechanism for improvement,
now that manualized trauma focused therapies are rather than a verbal repeated retelling as in Prolonged
the first line treatments. This change was a result of Exposure therapy.
two large meta-analyses which did a head-to-head The verbal with imagining retelling of the
comparison between existing pharmacotherapy and trauma experience as is performed in PE is effective,
manualized psychotherapy with a comparison of though described as difficulty at best, by the patient
treatment outcomes. A manualized therapy is one in undergoing that type of therapy. Drop out rates
which the therapist or psychiatrist uses a guide manual from PE tend to be higher than that of other more
to assist in care delivery, ensuring that all important cognitively-focused therapies such as CPT and EMDR.
trauma related topics are addressed. Use of a manual Written exposure therapy provides a mid point
for trauma therapy is the gold standard for treatment between the two with emerging data suggesting a much
delivery. It was noted in both that the psychotherapy improved retention rate in therapy when compared to
alone presented a longer duration of symptom PE.
resolution with a reduction in risk of side effects from There is strong evidence for:
ongoing medication use amongst the studied patient • Individual, manualized trauma-focused
populations.12 psychotherapy, 12-20, 60-minute sessions weekly,
In conjunction with specific positive research as main and first line treatment for treatment of
supporting use of manualized, trauma-focused PTSD.
therapies such as PE, EMDR, and CPT have shown • Cognitive Processing Therapy
consistent reduction of symptoms of PTSD with • Eye Movement Desensitization and Restructuring (
completion of 12-16, 60 minute weekly sessions.13,14,15 • Written Exposure Therapy
While those three ‘main’ trauma therapies have been • Narrative Exposure Therapy
the foundation of trauma-focused therapy research, • Prolonged Exposure
new subtypes of manualized focused therapy such • Any of the above therapies delivered through video
as cognitive behavioral therapy for PTSD (CBT for teleconferencing (aka, virtual health)
PTSD), Narrative Exposure Therapy (NET) and
Written Exposure have also shown evidence to support Pharmacologic Treatment of PTSD
their use in treatment.16,17,18, 19 All of the therapies
that have shown the greatest treatment benefit have Pharmacotherapy as a Treatment for PTSD
been individual therapy, not group. Recent research (Strong Recommendation for)
also highlights that therapy through video call is as As based on the most relevant and recent research, the
effective as in person and is a cost effective first line medications fluoxetine, venlafaxine, or paroxetine have
treatment strategy.20 Use of a manual to guide and shown the most benefit as monotherapy in treatment

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of posttraumatic stress disorder symptomology. The SNRI in anxiolytic effects. As a nightly anxiolytic
relative benefits of use of the selective serotonin this medication not only improves sleep architecture
reuptake inhibitors (SSRI) or selective norepinephrine but may reduce anxiety symptoms in as early as two
reuptake inhibitors (SNRI) are that the side effect to three weeks which can be a remarkable benefit to
profiles are generally well tolerated. In clinical practice a those who do respond well to it—especially those not
psychiatrist will often switch to different SSRI or SNRI with PTSD but with Generalized Anxiety Disorder
medications based on patient response, tolerability, or Panic Disorder, with or without Agoraphobia.
or other issues of slow or rapid metabolism of those It is also important to note that all medications
particular medications. Specifically, paroxetine is less targeting reduction of anxiety symptoms tend to
prescribed as it tends to have greater anticholinergic assist in reduction of the active anxiety components
side effect profiles than the other SSRIs and has an of PTSD rather than decreasing the avoidant and
extremely short half-life often requiring twice daily negative symptoms of post traumatic stress disorder.
dosing. Other medications such as des-venlafaxine This again leaves therapy is the primary choice a first
and duloxetine are both acceptable alternatives, as line treatments in that it can address all aspects of
is sertraline in the treatment of post traumatic stress symptomology.
disorder. Specifically noted Celexa and Lexapro in the Weak or insufficient evidence for augmentation
research have a less significant impact on reduction of with:
symptoms than these other medications.21 • Prazosin, for reduction of nightmares/hyper
arousal symptoms
There is strong evidence for use of the following
• Mirtazapine, for augmentation with an SSRI or
medications for treatment of PTSD:
SNRI and sleep benefit for PTSD
• Fluoxetine, initial dose 10-20mg daily, response
• PTSD Non-Advised Treatments
range 20-80mg daily.
Given the amount of research conducted over
• Paroxetine, initial dose 10-20mg daily, response
the last two decades, and the interest in PTSD as a
range 20-50mg daily. diagnosis due to the active military conflicts over that
• Sertraline, initial dose 25-50mg daily, response same time period, many medications have also been
range 50-200mg daily. studied. Of particular note, benzodiazepines have been
• Venlafaxine XR, initial dose 37.5mg daily, response found to carry a ‘strong against’ use recommendation.
range 75-225mg daily. In some studies that class of medications carries an
• Augmentation Strategies (Weak or Insufficient ‘X’ recommendation as well due to evidence that
Evidence for) they cause harm with long term use with a diagnosis
of PTSD. This is thought to be due to the strong
Augmentation strategies (Weak or Insufficient sedative, addictive, and dissociative properties of the
Evidence for) benzodiazepines (sedative hypnotics) when used to
Augmentation strategies for treatment resistant attempt to treat a condition in which dissociation
comorbid symptomology can be done in conjunction and hypnotic sedation fosters trauma reliving
with a primary SSRI or SSRI. The most studied of intrusive symptoms which in turn worsened avoidant
these medications include the short half-life alpha symptoms of PTSD. That said, acute or emergent use
adrenergic antagonist prazosin for the treatment of benzodiazepines for reduction of imminent risk
of PTSD associated nightmares and hyper arousal aggression in an emergency room or inpatient setting,
response, though recent research concluded that or to treat seizures or alcohol withdrawals is medically
there was only weak evidence for use in some studies indicated and does not worsen outcome of PTSD
even in this limited capacity. Typical dose ranges for symptoms. Other medications studied included all
prazosin range from 1-12mg usually nightly, though anti-convulsants, which are often used in psychiatry
some individuals may respond well to a split dosing as mood stabilizers to treat both subtypes of bipolar
regimen with a smaller morning dose and larger disorder, and many typical and atypical antipsychotic
even dose. Another augmentation medication with medications which have been shown to be of benefit
weak evidence for use is mirtazepine, dosed to target in treatment resistant major depressive disorders, in
reduction of sleep latency, improvement of sleep psychotic disorders such as schizophrenia, and also in
duration, and augmentation of the primary SSRI or bipolar disorders.

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Additional procedures that have been effective in References

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