Editing Post-traumatic stress disorder (section)

== Management ==
{{further|Treatments for PTSD}}

Reviews of studies have found that combination therapy (psychological and pharmacotherapy) is no more effective than psychological therapy alone.<ref name="pmid20614457" />

=== Counselling ===
The approaches with the strongest evidence include behavioral and cognitive-behavioral therapies such as [[exposure therapy|prolonged exposure therapy]],<ref>{{cite journal |vauthors=Powers MB, Halpern JM, Ferenschak MP, Gillihan SJ, Foa EB |title=A meta-analytic review of prolonged exposure for posttraumatic stress disorder |journal=[[Clinical Psychology Review]] |volume=30 |issue=6 |pages=635–41 |date=August 2010 |pmid=20546985 |doi=10.1016/j.cpr.2010.04.007}}</ref> [[cognitive processing therapy]] (CBT), and [[eye movement desensitization and reprocessing]] (EMDR).<ref>{{Cite book |url=http://www.apa.org/ptsd-guideline/ |title=Clinical Practice Guideline for the Treatment of Posttraumatic Stress Disorder (PTSD) in Adults |last=Guideline Development Panel for the Treatment of PTSD in Adults |publisher=[[American Psychological Association]] |year=2017 |location=Washington, D.C. |pages=ES–2 |format=PDF}}</ref><ref name="pmid23266601">{{cite journal |vauthors=Lee CW, Cuijpers P |title=A meta-analysis of the contribution of eye movements in processing emotional memories |journal=[[Journal of Behavior Therapy and Experimental Psychiatry]] |volume=44 |issue=2 |pages=231–9 |date=June 2013 |pmid=23266601 |doi=10.1016/j.jbtep.2012.11.001 |url=http://researchrepository.murdoch.edu.au/id/eprint/13100/ |type=Submitted manuscript}}</ref><ref>{{cite book |vauthors=Cahill SP, Foa EB |year=2004 |title=Advances in the Treatment of Posttraumatic Stress Disorder: Cognitive-behavioral perspectives |veditors=Taylor S |pages=267–313 |place=New York |publisher=Springer}}</ref><ref>{{Cite report |url=https://effectivehealthcare.ahrq.gov/topics/ptsd-adult-treatment-update/research-2018 |title=Psychological and Pharmacological Treatments for Adults With Posttraumatic Stress Disorder: A Systematic Review Update |last1=Forman-Hoffman |first1=Valerie |last2=Cook Middleton |first2=Jennifer |date=2018-05-17 |publisher=Agency for Healthcare Research and Quality (AHRQ) |doi=10.23970/ahrqepccer207 |last3=Feltner |first3=Cynthia |last4=Gaynes |first4=Bradley N. |last5=Palmieri Weber |first5=Rachel |last6=Bann |first6=Carla |last7=Viswanathan |first7=Meera |last8=Lohr |first8=Kathleen N. |last9=Baker |first9=Claire}}</ref> There is some evidence for brief eclectic psychotherapy (BEP), [[narrative exposure therapy]] (NET), and written exposure therapy.<ref>{{cite book |vauthors=Sloan DM, Marx BP |date=2019 |url=http://content.apa.org/books/16117-007|title=Written exposure therapy for PTSD: A brief treatment approach for mental health professionals |place=Washington |publisher=[[American Psychological Association]] |language=en |doi=10.1037/0000139-001 |isbn=978-1-4338-3013-6 |access-date=2022-02-13|s2cid=239337813}}</ref><ref>{{cite book |title=VA/DOD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder |date=2017 |publisher=United States [[Department of Veterans Affairs]] |pages=46–47 |url=https://www.healthquality.va.gov/guidelines/MH/ptsd/VADoDPTSDCPGFinal012418.pdf}}</ref>

A 2019 Cochrane review evaluated couples and family therapies compared to no care and individual and group therapies for the [[Treatments for PTSD|treatment of PTSD]].<ref name="Suomi_2019">{{cite journal |vauthors=Suomi A, Evans L, Rodgers B, Taplin S, Cowlishaw S |title=Couple and family therapies for post-traumatic stress disorder (PTSD) |journal=[[Cochrane Library|The Cochrane Database of Systematic Reviews]] |volume=2019 |pages=CD011257 |date=December 2019 |issue=12 |pmid=31797352 |pmc=6890534 |doi=10.1002/14651858.CD011257.pub2}}</ref> There were too few studies on couples therapies to determine if substantive benefits were derived, but preliminary [[Randomized controlled trial|RCTs]] suggested that couples therapies may be beneficial for reducing PTSD symptoms.<ref name="Suomi_2019" />

A [[meta-analysis|meta-analytic]] comparison of EMDR and CBT found both protocols indistinguishable in terms of effectiveness in treating PTSD; however, "the contribution of the eye movement component in EMDR to treatment outcome" is unclear.<ref>{{cite journal |vauthors=Seidler GH, Wagner FE |title=Comparing the efficacy of EMDR and trauma-focused cognitive-behavioral therapy in the treatment of PTSD: a meta-analytic study |journal=[[Psychological Medicine]] |volume=36 |issue=11 |pages=1515–22 |date=November 2006 |pmid=16740177 |doi=10.1017/S0033291706007963 |s2cid=39751799}}</ref> A meta-analysis in children and adolescents also found that EMDR was as efficacious as CBT.<ref name=MetaNSUE>{{cite journal |vauthors=Moreno-Alcázar A, Treen D, Valiente-Gómez A, Sio-Eroles A, Pérez V, Amann BL, Radua J |title=Efficacy of Eye Movement Desensitization and Reprocessing in Children and Adolescent with Post-traumatic Stress Disorder: A Meta-Analysis of Randomized Controlled Trials |journal=[[Frontiers in Psychology]] |volume=8 |pages=1750 |year=2017 |pmid=29066991 |pmc=5641384 |doi=10.3389/fpsyg.2017.01750 |doi-access=free}}</ref>

Children with PTSD are far more likely to pursue treatment at school (because of its proximity and ease) than at a free clinic.<ref>{{cite journal |vauthors=Rolfsnes ES, Idsoe T |title=School-based intervention programs for PTSD symptoms: a review and meta-analysis |journal=[[Journal of Traumatic Stress]] |volume=24 |issue=2 |pages=155–65 |date=April 2011 |pmid=21425191 |doi=10.1002/jts.20622}}</ref>

==== Cognitive behavioral therapy ====
{{Main|Trauma focused cognitive behavioral therapy}}
[[File:Depicting basic tenets of CBT.jpg|thumb|The diagram depicts how emotions, thoughts, and behaviors all influence each other. The triangle in the middle represents CBT's tenet that all humans' core beliefs can be summed up in three categories: self, others, future.]]

CBT seeks to change the way a person feels and acts by changing the patterns of thinking or behavior, or both, responsible for negative emotions. Results from a 2018 systematic review found high strength of evidence that supports CBT-exposure therapy efficacious for a reduction in PTSD and depression symptoms, as well as the loss of PTSD diagnosis.<ref name="Forman-Hoffman_2018"/> CBT has been proven to be an effective [[Treatments for PTSD|treatment for PTSD]] and is currently considered the standard of care for PTSD by the [[United States Department of Defense]].<ref>{{cite web |title=Treatment of PTSD – PTSD: National Center for PTSD |url=http://www.ptsd.va.gov/public/treatment/therapy-med/treatment-ptsd.asp |publisher=U.S. [[Department of Veterans Affairs]] |date=May 26, 2016 |url-status=live |archive-url=https://web.archive.org/web/20161201110743/http://www.ptsd.va.gov/public/treatment/therapy-med/treatment-ptsd.asp |archive-date=December 1, 2016}}</ref><ref>{{cite news |title=PTSD Treatment Options |url=http://dcoe.mil/PsychologicalHealth/About_PTSD/Treatment_Options.aspx |newspaper=Defense Centers of Excellence |date=November 23, 2016 |url-status=live |archive-url=https://web.archive.org/web/20161130035254/http://dcoe.mil/PsychologicalHealth/About_PTSD/Treatment_Options.aspx |archive-date=November 30, 2016}}</ref>

In CBT, individuals learn to identify thoughts that make them feel afraid or upset and replace them with less distressing thoughts. The goal is to understand how certain thoughts about events cause PTSD-related stress.<ref>{{Cite web |url=http://www.apa.org/ptsd-guideline/treatments/cognitive-behavioral-therapy.aspx |title=Cognitive Behavioral Therapy (CBT) for Treatment of PTSD |publisher=[[American Psychiatric Association]] |archive-url=https://web.archive.org/web/20180109063624/http://www.apa.org/ptsd-guideline/treatments/cognitive-behavioral-therapy.aspx |archive-date=2018-01-09 |access-date=2018-01-08}}</ref><ref>{{Cite web |url=https://www.ptsd.va.gov/public/treatment/therapy-med/treatment-ptsd.asp |title=Treatment of PTSD – PTSD |publisher=[[National Center for PTSD]] |access-date=2018-01-08}}</ref> A study assessing an online version of CBT for people with mild-to-moderate PTSD found that the online approach was as effective as, and cheaper than, the same therapy given face-to-face.<ref>{{Cite journal |date=27 January 2023 |title=Online CBT for post-traumatic stress disorder is as effective as face-to-face therapy |url=https://evidence.nihr.ac.uk/alert/online-cbt-for-ptsd-is-as-effective-as-face-to-face-therapy/ |journal=NIHR Evidence|doi=10.3310/nihrevidence_56507 |s2cid=257844874 |url-access=subscription }}</ref><ref>{{cite journal | vauthors = Bisson JI, Ariti C, Cullen K, Kitchiner N, Lewis C, Roberts NP, Simon N, Smallman K, Addison K, Bell V, Brookes-Howell L, Cosgrove S, Ehlers A, Fitzsimmons D, Foscarini-Craggs P, Harris SR, Kelson M, Lovell K, McKenna M, McNamara R, Nollett C, Pickles T, Williams-Thomas R | title = Guided, internet based, cognitive behavioural therapy for post-traumatic stress disorder: pragmatic, multicentre, randomised controlled non-inferiority trial (RAPID) | journal = BMJ | volume = 377 | pages = e069405 | date = June 2022 | pmid = 35710124 | pmc = 9202033 | doi = 10.1136/bmj-2021-069405 }}</ref> A 2021 Cochrane review assessed the provision of CBT in an Internet-based format found similar beneficial effects for [[Internet-based treatments for trauma survivors|Internet-based therapy]] as in face-to-face. However, the quality of the evidence was low due to the small number of trials reviewed.<ref>{{cite journal | vauthors = Simon N, Robertson L, Lewis C, Roberts NP, Bethell A, Dawson S, Bisson JI | title = Internet-based cognitive and behavioural therapies for post-traumatic stress disorder (PTSD) in adults | journal = The Cochrane Database of Systematic Reviews | volume = 2021 | issue = 5 | pages = CD011710 | date = May 2021 | pmid = 34015141 | pmc = 8136365 | doi = 10.1002/14651858.CD011710.pub3 }}</ref>

Exposure therapy is a type of cognitive behavioral therapy<ref>{{cite web |vauthors=Grohol JM |date=2016-05-17 |title=What Is Exposure Therapy? |work=Psych Central.com |url=http://psychcentral.com/lib/2009/what-is-exposure-therapy/ |access-date=2010-07-14 |publisher=Psychcentral.com |url-status=live |archive-url=https://web.archive.org/web/20100811161615/http://psychcentral.com/lib/2009/what-is-exposure-therapy/ |archive-date=2010-08-11}}</ref> that involves assisting trauma survivors to re-experience distressing trauma-related memories and reminders in order to facilitate habituation and successful emotional processing of the trauma memory. Most exposure therapy programs include both imaginal confrontation with the [[traumatic memories]] and real-life exposure to trauma reminders; this type of CBT has shown benefit in the [[Treatments for PTSD|treatment of PTSD]].<ref name="McLean 2022">{{cite journal |last1=McLean |first1=Carmen P. |last2=Levy |first2=Hannah C. |last3=Miller |first3=Madeleine L. |last4=Tolin |first4=David F. |title=Exposure therapy for PTSD: A meta-analysis |journal=Clinical Psychology Review |date=February 2022 |volume=91 |pages=102115 |doi=10.1016/j.cpr.2021.102115|pmid=34954460 |s2cid=245394152 }}</ref><ref name="Shalev 2017" />

Some organizations{{which|date=December 2011}} have endorsed the need for exposure.<ref name="pmid15617511">{{cite journal |vauthors=Ursano RJ, Bell C, Eth S, Friedman M, Norwood A, Pfefferbaum B, Pynoos JD, Zatzick DF, Benedek DM, McIntyre JS, Charles SC, Altshuler K, Cook I, Cross CD, Mellman L, Moench LA, Norquist G, Twemlow SW, Woods S, Yager J |title=Practice guideline for the treatment of patients with acute stress disorder and posttraumatic stress disorder |journal=The American Journal of Psychiatry |volume=161 |issue=11 Suppl |pages=3–31 |date=November 2004 |pmid=15617511}}</ref><ref>{{cite book |title=Committee on Treatment of Posttraumatic Stress Disorder, Institute of Medicine: Treatment of Posttraumatic Stress Disorder: An Assessment of the Evidence |place=Washington, D.C. |publisher=National Academies Press |year=2008 |isbn=978-0-309-10926-0}}{{page needed|date=January 2014}}</ref> The U.S. Department of Veterans Affairs has been actively training mental health treatment staff in [[prolonged exposure therapy]]<ref>{{cite web |title=Prolonged Exposure Therapy |date=2009-09-29 |publisher=U.S. Department of Veteran Affairs |url=http://www.ptsd.va.gov/public/pages/prolonged-exposure-therapy.asp |access-date=2010-07-14 |archive-url=https://web.archive.org/web/20091114064548/http://www.ptsd.va.gov/public/pages/prolonged-exposure-therapy.asp |archive-date=2009-11-14 |department=PTSD: National Center for PTSD}}</ref> and [[cognitive processing therapy]]<ref>{{cite journal |vauthors=Karlin BE, Ruzek JI, Chard KM, Eftekhari A, Monson CM, Hembree EA, Resick PA, Foa EB |title=Dissemination of evidence-based psychological treatments for posttraumatic stress disorder in the Veterans Health Administration |journal=[[Journal of Traumatic Stress]] |volume=23 |issue=6 |pages=663–73 |date=December 2010 |pmid=21171126 |doi=10.1002/jts.20588}}</ref> in an effort to better treat U.S. veterans with PTSD.

Recent research on contextually based [[behavior therapy#Third generation|third-generation behavior therapies]] suggests that they may produce results comparable to some of the better validated therapies.<ref>{{cite journal |vauthors=Mulick PS, Landes S, Kanter JW |year=2005 |title=Contextual Behavior Therapies in the Treatment of PTSD: A Review |journal=International Journal of Behavioral Consultation and Therapy |volume=1 |issue=3 |pages=223–228 |doi=10.1037/h0100747 |url=http://www.uwm.edu/~jkanter/pdf/publication/IJBCT-1-3.pdf |archive-url=https://wayback.archive-it.org/all/20120916131249/http://www.uwm.edu/~jkanter/pdf/publication/IJBCT-1-3.pdf |archive-date=16 September 2012 |citeseerx=10.1.1.625.4407}}</ref> Many of these therapy methods have a significant element of exposure<ref name="Hassija 2007">{{cite journal |vauthors=Hassija CM, Gray MJ |year=2007 |title=Behavioral Interventions for Trauma and Posttraumatic Stress Disorder |journal=International Journal of Behavioral Consultation and Therapy |volume=3 |issue=2 |pages=166–175 |doi=10.1037/h0100797 |url=http://eric.ed.gov/ERICWebPortal/contentdelivery/servlet/ERICServlet?accno=EJ801196|url-access=subscription }}</ref> and have demonstrated success in treating the primary problems of PTSD and co-occurring depressive symptoms.<ref>{{cite journal |vauthors=Mulick PS, Naugle AE |year=2009 |title=Behavioral Activation in the Treatment of Comorbid Posttraumatic Stress Disorder and Major Depressive Disorder |journal=International Journal of Behavioral Consultation and Therapy |volume=5 |issue=2 |pages=330–339 |doi=10.1037/h0100892 |url=http://www.thefreelibrary.com/Behavioral+activation+in+the+treatment+of+comorbid+posttraumatic...-a0221920130}}</ref>

==== Eye movement desensitization and reprocessing ====
{{Main|Eye movement desensitization and reprocessing}}
Eye movement desensitization and reprocessing (EMDR) is a form of psychotherapy developed and studied by [[Francine Shapiro]].<ref name="Shapiro F 1989 199–223">{{cite journal |vauthors=Shapiro F |title=Efficacy of the eye movement desensitization procedure in the treatment of traumatic memories |journal=[[Journal of Traumatic Stress]] |date=April 1989 |volume=2 |issue=2 |pages=199–223 |doi=10.1002/jts.2490020207}}</ref> She had noticed that, when she was thinking about disturbing memories herself, her eyes were moving rapidly. When she brought her eye movements under control while thinking, the thoughts were less distressing.<ref name="Shapiro F 1989 199–223" />

In 2002, Shapiro and Maxfield published a theory of why this might work, called adaptive information processing.<ref>{{cite journal |vauthors=Shapiro F, Maxfield L |title=Eye Movement Desensitization and Reprocessing (EMDR): information processing in the treatment of trauma |journal=[[Journal of Clinical Psychology]] |volume=58 |issue=8 |pages=933–46 |date=August 2002 |pmid=12115716 |doi=10.1002/jclp.10068}}</ref> This theory proposes that eye movement can be used to facilitate emotional processing of memories, changing the person's memory to attend to more adaptive information.<ref name=VAguideline>{{cite web |last=The Management of Post-Traumatic Stress Working Group |title=VA/DoD clinical practice guideline for management of post-traumatic stress |url=http://www.healthquality.va.gov/Post_Traumatic_Stress_Disorder_PTSD.asp |access-date=2 June 2013 |publisher=Department of Veterans Affairs, Department of Defense |page=Version 2.0 |year=2010 |url-status=live |archive-url=https://web.archive.org/web/20130530234757/http://www.healthquality.va.gov/Post_Traumatic_Stress_Disorder_PTSD.asp |archive-date=30 May 2013}}</ref> The therapist initiates voluntary rapid eye movements while the person focuses on memories, feelings or thoughts about a particular trauma.<ref name=UK2005/><ref name=CochraneGilliesKids>{{cite journal |vauthors=Gillies D, Taylor F, Gray C, O'Brien L, D'Abrew N |title=Psychological therapies for the treatment of post-traumatic stress disorder in children and adolescents |journal=[[Cochrane Library|The Cochrane Database of Systematic Reviews]] |volume=12 |pages=CD006726 |date=December 2012 |pmid=23235632 |doi=10.1002/14651858.CD006726.pub2 |hdl=1959.13/1311467 |hdl-access=free}}</ref> The therapist uses hand movements to get the person to move their eyes backward and forward, but hand-tapping or tones can also be used.<ref name=UK2005/> EMDR closely resembles [[cognitive behavior therapy]] as it combines exposure (re-visiting the traumatic event), working on cognitive processes and relaxation/self-monitoring.<ref name=UK2005/> However, exposure by way of being asked to think about the experience rather than talk about it has been highlighted as one of the more important distinguishing elements of EMDR.<ref name="Jeffries/Davis">{{cite journal |vauthors=Jeffries FW, Davis P |title=What is the role of eye movements in eye movement desensitization and reprocessing (EMDR) for post-traumatic stress disorder (PTSD)? a review |journal=[[Behavioural and Cognitive Psychotherapy]] |volume=41 |issue=3 |pages=290–300 |date=May 2013 |pmid=23102050 |doi=10.1017/S1352465812000793 |s2cid=33309479}}</ref>

Several scientific studies have evaluated the efficacy of EMDR in adults<ref name="AHRQtreat92">{{Cite book |vauthors=Jonas DE, Cusack K, Forneris CA |title=Psychological and pharmacological treatments for adults with posttraumatic stress disorder (PTSD) |publisher=Agency for Healthcare Research and Quality |url=https://www.ncbi.nlm.nih.gov/books/NBK137702/ |series=Comparative Effectiveness Reviews No. 92 |date=April 2013 |location=Rockville, MD |pmid=23658937 |url-status=live |archive-url=https://web.archive.org/web/20170118124526/https://www.ncbi.nlm.nih.gov/books/NBK137702/ |archive-date=2017-01-18}}</ref> as well as children and adolescents.<ref name="CochraneGilliesKids" /> There is moderate strength of evidence to support the efficacy of EMDR "for reduction in PTSD symptoms, loss of diagnosis, and reduction in depressive symptoms" according to a 2018 systematic review update.<ref name="Forman-Hoffman_2018" /> 

In children and adolescents, a recent meta-analysis of [[randomized controlled trials]] found that EMDR was at least as efficacious as CBT, and superior to waitlist or placebo.<ref name=MetaNSUE/> There was some evidence that EMDR might prevent depression.<ref name="AHRQtreat92" /> Adverse effects were largely unstudied.<ref name="AHRQtreat92" /> The benefits were greater for women with a history of sexual assault compared with people who had experienced other types of traumatizing events (such as accidents, physical assaults and war).

The eye movement component of the therapy may not be critical for benefit.<ref name="UK2005" /><ref name="VAguideline" /> 

==== Interpersonal psychotherapy ====
Other approaches, in particular involving social supports,<ref name="Brewin">{{cite journal |vauthors=Brewin CR, Andrews B, Valentine JD |title=Meta-analysis of risk factors for posttraumatic stress disorder in trauma-exposed adults |journal=[[Journal of Consulting and Clinical Psychology]] |volume=68 |issue=5 |pages=748–66 |date=October 2000 |pmid=11068961 |doi=10.1037/0022-006X.68.5.748 |s2cid=13749007 |url=http://content.apa.org/journals/ccp/68/5/748}}</ref><ref name=Ozer>{{cite journal |vauthors=Ozer EJ, Best SR, Lipsey TL, Weiss DS |title=Predictors of posttraumatic stress disorder and symptoms in adults: a meta-analysis |journal=[[Psychological Bulletin]] |volume=129 |issue=1 |pages=52–73 |date=January 2003 |pmid=12555794 |doi=10.1037/0033-2909.129.1.52 |url=http://content.apa.org/journals/bul/129/1/52}}</ref> may also be important. An open trial of interpersonal psychotherapy reported high rates of remission from PTSD symptoms without using exposure.<ref>{{cite journal |vauthors=Bleiberg KL, Markowitz JC |title=A pilot study of interpersonal psychotherapy for posttraumatic stress disorder |journal=The American Journal of Psychiatry |volume=162 |issue=1 |pages=181–3 |date=January 2005 |pmid=15625219 |doi=10.1176/appi.ajp.162.1.181}}</ref>

=== Medication ===
Four antidepressants (sertraline, fluoxetine, paroxetine, and venlafaxine) have been shown to have a small to modest benefit over placebo.<ref name="Hos2015"/> 

==== Antidepressants ====
[[Selective serotonin reuptake inhibitors]] (SSRIs) and [[serotonin–norepinephrine reuptake inhibitor]]s (SNRIs) may have some benefit for PTSD symptoms.<ref name=Hos2015/><ref name=Jeffreys-2012>{{cite journal |vauthors=Jeffreys M, Capehart B, Friedman MJ |title=Pharmacotherapy for posttraumatic stress disorder: review with clinical applications |journal=[[Journal of Rehabilitation Research and Development]] |volume=49 |issue=5 |pages=703–715 |date=2012 |pmid=23015581 |doi=10.1682/JRRD.2011.09.0183 |quote=While evidence-based, trauma-focused psychotherapy is the preferred treatment for PTSD, pharmacotherapy is also an important treatment option. First-line pharmacotherapy agents include selective serotonin reuptake inhibitors and the selective serotonin-norepinephrine reuptake inhibitor venlafaxine. |doi-access=free}}</ref><ref>{{cite journal |vauthors=Williams T, Phillips NJ, Stein DJ, Ipser JC |title=Pharmacotherapy for post traumatic stress disorder (PTSD) |journal=[[Cochrane Library|The Cochrane Database of Systematic Reviews]] |volume=2022 |issue=3 |pages=CD002795 |date=March 2022 |pmid=35234292 |pmc=8889888 |doi=10.1002/14651858.CD002795.pub3 }}</ref> [[Tricyclic antidepressants]] are equally effective, but are less well tolerated.<ref>{{cite journal |vauthors=Puetz TW, Youngstedt SD, Herring MP |title=Effects of Pharmacotherapy on Combat-Related PTSD, Anxiety, and Depression: A Systematic Review and Meta-Regression Analysis |journal=[[PLOS ONE]] |volume=10 |issue=5 |pages=e0126529 |date=28 May 2015 |pmid=26020791 |pmc=4447407 |doi=10.1371/journal.pone.0126529 |veditors=Hashimoto K |quote=The cumulative evidence summarized in this review indicates that pharmacotherapy significantly reduces PTSD, anxiety, and depressive symptom severity among combat veterans with PTSD. The magnitude of the overall effects of pharmacotherapy on PTSD (Δ = 0.38), anxiety (Δ = 0.42), and depressive symptoms (Δ = 0.52) were moderate... |doi-access=free |bibcode=2015PLoSO..1026529P}}</ref> Evidence provides support for a small or modest improvement with [[sertraline]], [[fluoxetine]], [[paroxetine]], and [[venlafaxine]].<ref name=Hos2015/><ref>{{cite journal |vauthors=Kapfhammer HP |title=Patient-reported outcomes in post-traumatic stress disorder. Part II: focus on pharmacological treatment |language=en, es, fr |journal=[[Dialogues in Clinical Neuroscience]] |volume=16 |issue=2 |pages=227–237 |date=June 2014 |pmid=25152660 |pmc=4140515 |doi=10.31887/DCNS.2014.16.2/hkapfhammer}}</ref> Thus, these four medications are considered to be [[First-line treatment|first-line]] medications for PTSD.<ref name=Jeffreys-2012/><ref name="Berger-2009"/> The SSRIs paroxetine and sertraline are approved by the U.S. [[Food and Drug Administration]] (FDA) approved for the [[Treatments for PTSD|treatment of PTSD]].<ref name="Shalev 2017" />

==== Benzodiazepines ====
[[Benzodiazepine]]s are not recommended for the [[Treatments for PTSD|treatment of PTSD]] due to a lack of evidence of benefit and risk of worsening PTSD symptoms.<ref name="pmid22302333">{{cite journal |vauthors=Jain S, Greenbaum MA, Rosen C |title=Concordance between psychotropic prescribing for veterans with PTSD and clinical practice guidelines |journal=[[Psychiatric Services]] |volume=63 |issue=2 |pages=154–60 |date=February 2012 |pmid=22302333 |doi=10.1176/appi.ps.201100199}}</ref> Some authors believe that the use of benzodiazepines is contraindicated for acute stress, as this group of drugs can cause [[Dissociation (psychology)|dissociation]].<ref name="pmid23062450">{{cite journal |vauthors=Auxéméry Y |title=[Posttraumatic stress disorder (PTSD) as a consequence of the interaction between an individual genetic susceptibility, a traumatogenic event and a social context] |language=fr |journal=[[L'Encéphale]] |volume=38 |issue=5 |pages=373–80 |date=October 2012 |pmid=23062450 |doi=10.1016/j.encep.2011.12.003}}</ref> Nevertheless, some use benzodiazepines with caution for short-term anxiety and insomnia.<ref name="Kapfhammer-2008">{{cite journal |vauthors=Kapfhammer HP |title=[Therapeutic possibilities after traumatic experiences] |journal=[[Psychiatria Danubina]] |volume=20 |issue=4 |pages=532–45 |date=December 2008 |pmid=19011595}}</ref><ref name="autogenerated1">{{cite book | vauthors = Reist C |date=2005 |title=Post-traumatic Stress Disorder |location= |publisher=Epocrates.com}}</ref><ref name="Maxmen2002-349">{{cite book |vauthors=Maxmen JS, Ward NG |title=Psychotropic drugs: fast facts |place=New York |publisher=[[W.W. Norton & Company]] |year=2002 |edition=3rd |isbn=978-0-393-70301-6 |page=349}}</ref> While benzodiazepines can alleviate acute anxiety, there is no consistent evidence that they can stop the development of PTSD and may actually increase the risk of developing PTSD 2–5 times.<ref name=Gui2015/> Benzodiazepines should not be used in the immediate aftermath of a traumatic event as they may increase symptoms related to PTSD.<ref name="Shalev 2017" />

Benzodiazepines may reduce the effectiveness of psychotherapeutic interventions, and there is some evidence that benzodiazepines may actually contribute to the development and chronification of PTSD. For those who already have PTSD, benzodiazepines may worsen and prolong the course of illness, by worsening psychotherapy outcomes, and causing or exacerbating aggression, depression (including suicidality), and substance use.<ref name=Gui2015/> Drawbacks include the risk of developing a [[benzodiazepine dependence]], [[Drug tolerance|tolerance]] (i.e., short-term benefits wearing off with time), and [[benzodiazepine withdrawal syndrome|withdrawal syndrome]]; additionally, individuals with PTSD (even those without a history of alcohol or drug misuse) are at an increased risk of [[benzodiazepine misuse|abusing benzodiazepines]].<ref name="Berger-2009" /><ref name="Martényi-2005">{{cite journal |vauthors=Martényi F |title=[Three paradigms in the treatment of posttraumatic stress disorder] |journal=[[Neuropsychopharmacologia Hungarica]] |volume=7 |issue=1 |pages=11–21 |date=March 2005 |pmid=16167463}}</ref>

Due to a number of other treatments with greater efficacy for PTSD and fewer risks, benzodiazepines should be considered [[Contraindicated|relatively contraindicated]] until all other treatment options are exhausted.<ref name=Haa2015/><ref name="VA/DoD_2010"/>

Benzodiazepines also carry a risk of disinhibition (associated with suicidality, aggression and crimes) and their use may delay or inhibit more definitive [[treatments for PTSD]].<ref name="Berger-2009"/><ref name="VA/DoD_2010">{{Cite book |title=Veterans Affairs and Department of Defense clinical practice guideline for management of post-traumatic stress. |publisher=VA/DoD |year=2010}}</ref><ref>{{cite journal |vauthors=Bandelow B, Zohar J, Hollander E, Kasper S, Möller HJ, Zohar J, Hollander E, Kasper S, Möller HJ, Bandelow B, Allgulander C, Ayuso-Gutierrez J, Baldwin DS, Buenvicius R, Cassano G, Fineberg N, Gabriels L, Hindmarch I, Kaiya H, Klein DF, Lader M, Lecrubier Y, Lépine JP, Liebowitz MR, Lopez-Ibor JJ, Marazziti D, Miguel EC, Oh KS, Preter M, Rupprecht R, Sato M, Starcevic V, Stein DJ, van Ameringen M, Vega J |title=World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for the pharmacological treatment of anxiety, obsessive-compulsive and post-traumatic stress disorders – first revision |journal=The World Journal of Biological Psychiatry |volume=9 |issue=4 |pages=248–312 |year=2008 |pmid=18949648 |doi=10.1080/15622970802465807 |doi-access=free}}</ref>

==== Prazosin ====
[[Prazosin]], an alpha-1 adrenergic antagonist, has been used in veterans with PTSD to reduce nightmares. Studies show variability in the symptom improvement, appropriate dosages, and efficacy in this population.<ref>{{cite journal |vauthors=Green B |s2cid=40069887 |title=Prazosin in the treatment of PTSD |journal=[[Journal of Psychiatric Practice]] |volume=20 |issue=4 |pages=253–9 |date=July 2014 |doi=10.1097/01.pra.0000452561.98286.1e |pmid=25036580}}</ref><ref>{{cite journal |vauthors=Singh B, Hughes AJ, Mehta G, Erwin PJ, Parsaik AK |title=Efficacy of Prazosin in Posttraumatic Stress Disorder: A Systematic Review and Meta-Analysis |journal=The Primary Care Companion for CNS Disorders |volume=18 |issue=4 |date=July 2016 |pmid=27828694 |doi=10.4088/PCC.16r01943 }}</ref><ref name="Waltman_2018">{{cite journal |vauthors=Waltman SM, Shearer D, Moore BA |title=Management of Post-Traumatic Nightmares: a Review of Pharmacologic and Nonpharmacologic Treatments Since 2013 |journal=[[Current Psychiatry Reports]] |publisher=Springer Science and Business Media LLC |volume=20 |issue=12 |date=2018-10-11 |issn=1523-3812 |pmid=30306339 |doi=10.1007/s11920-018-0971-2 |page=108 |s2cid=52958432}}</ref>

==== Glucocorticoids ====
[[Glucocorticoids]] may be useful for short-term therapy to protect against neurodegeneration caused by the extended stress response that characterizes PTSD, but long-term use may actually promote neurodegeneration.<ref>{{cite journal |vauthors=Griffin GD, Charron D, Al-Daccak R |title=Post-traumatic stress disorder: revisiting adrenergics, glucocorticoids, immune system effects and homeostasis |journal=[[Clinical & Translational Immunology]] |volume=3 |issue=11 |pages=e27 |date=November 2014 |pmid=25505957 |pmc=4255796 |doi=10.1038/cti.2014.26}}</ref>

==== Cannabinoids ====
{{see also| Cannabis use and trauma}}
[[Cannabis (drug)|Cannabis]] is not recommended as a [[treatment for PTSD]] because scientific evidence does not currently exist demonstrating treatment efficacy for [[cannabinoid]]s.<ref>{{cite journal |vauthors=Black N, Stockings E, Campbell G, Tran LT, Zagic D, Hall WD, Farrell M, Degenhardt L |title=Cannabinoids for the treatment of mental disorders and symptoms of mental disorders: a systematic review and meta-analysis |journal=The Lancet. Psychiatry |volume=6 |issue=12 |pages=995–1010 |date=December 2019 |pmid=31672337 |pmc=6949116 |doi=10.1016/S2215-0366(19)30401-8}}</ref><ref>{{cite journal |vauthors=O'Neil ME, Nugent SM, Morasco BJ, Freeman M, Low A, Kondo K, Zakher B, Elven C, Motu'apuaka M, Paynter R, Kansagara D |title=Benefits and Harms of Plant-Based Cannabis for Posttraumatic Stress Disorder: A Systematic Review |journal=[[Annals of Internal Medicine]] |volume=167 |issue=5 |pages=332–340 |date=September 2017 |pmid=28806794 |doi=10.7326/M17-0477 |doi-access=free}}</ref>{{efn|As an ''example ''of such research, see: Bonn-Miller MO, Sisley S, Riggs P, Yazar-Klosinski B, Wang JB, Loflin MJE, et al. (2021) The short-term impact of 3 smoked cannabis preparations versus placebo on PTSD symptoms: A randomized cross-over clinical trial. ''PLOS ONE'' 16(3): e0246990.}} However, use of cannabis or derived products is widespread among U.S. veterans with PTSD.<ref>{{cite journal |vauthors=Betthauser K, Pilz J, Vollmer LE |title=Use and effects of cannabinoids in military veterans with posttraumatic stress disorder |journal=[[American Journal of Health-System Pharmacy]] |volume=72 |issue=15 |pages=1279–84 |date=August 2015 |pmid=26195653 |doi=10.2146/ajhp140523 |type=Review}}</ref>

The cannabinoid [[nabilone]] is sometimes used for nightmares in PTSD. Although some short-term benefit was shown, adverse effects are common and it has not been adequately studied to determine efficacy.<ref name=CADTH-Nabilone-2015>{{cite journal |title=Long-term Nabilone Use: A Review of the Clinical Effectiveness and Safety |journal=CADTH Rapid Response Reports |date=October 2015 |pmid=26561692 |url=https://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0079568/}}</ref> An increasing number of states permit and have legalized the use of [[medical cannabis]] for the treatment of PTSD.<ref>{{cite news |vauthors=Gregg K |url=http://www.providencejournal.com/news/20160713/raimondo-signs-law-allowing-marijuana-for-treatment-of-ptsd |title=Raimondo signs law allowing marijuana for treatment of PTSD |access-date=18 August 2016 |newspaper=[[The Providence Journal]] |date=2016-07-13 |url-status=live |archive-url= https://web.archive.org/web/20160816061718/http://www.providencejournal.com/news/20160713/raimondo-signs-law-allowing-marijuana-for-treatment-of-ptsd |archive-date=16 August 2016}}</ref>

=== Other ===

==== Exercise, sport and physical activity ====
Physical activity can influence people's psychological<ref name=CR-Lawrence>{{cite journal |vauthors=Lawrence S, De Silva M, Henley R |title=Sports and games for post-traumatic stress disorder (PTSD) |journal=[[Cochrane Library|The Cochrane Database of Systematic Reviews]] |issue=1 |pages=CD007171 |date=January 2010 |volume=2010 |pmid=20091620 |doi=10.1002/14651858.CD007171.pub2 |pmc=7390394 |url=https://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0014346/ |veditors=Lawrence S |archive-url=https://web.archive.org/web/20140201185206/http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0014346/ |url-status=live |archive-date=2014-02-01}}</ref> and physical health.<ref name=VA-Jankowski>{{cite web |vauthors=Jankowski K |title=PTSD and physical health |url=http://www.ptsd.va.gov/professional/pages/ptsd-physical-health.asp |archive-url=https://web.archive.org/web/20090730103610/http://www.ptsd.va.gov/professional/pages/ptsd-physical-health.asp |archive-date=30 July 2009 |work=Information on trauma and PTSD for professionals, National Center for PTSD |publisher=[[U.S. Department of Veterans Affairs]] |access-date=8 June 2013}}</ref> The U.S. National Center for PTSD recommends moderate exercise as a way to distract from disturbing emotions, build self-esteem and increase feelings of being in control again. They recommend a discussion with a doctor before starting an exercise program.<ref name=VA-Lifestylerecs>{{cite web |last=U.S. Department of Veterans Affairs |title=Lifestyle Changes Recommended for PTSD Patients |url=http://www.ptsd.va.gov/public/pages/coping-ptsd-lifestyle-changes.asp |archive-url=https://web.archive.org/web/20090731100807/http://www.ptsd.va.gov/public/pages/coping-ptsd-lifestyle-changes.asp |archive-date=31 July 2009 |work=Information on trauma and PTSD for veterans, general public and family from the National Center for PTSD |publisher=U.S. [[Department of Veterans Affairs]] |access-date=8 June 2013}}</ref>

==== Play therapy for children ====
Play is thought to help children link their inner thoughts with their outer world, connecting real experiences with abstract thought.<ref name=Wethington2008>{{cite journal |vauthors=Wethington HR, Hahn RA, Fuqua-Whitley DS, Sipe TA, Crosby AE, Johnson RL, Liberman AM, Mościcki E, Price LN, Tuma FK, Kalra G, Chattopadhyay SK |title=The effectiveness of interventions to reduce psychological harm from traumatic events among children and adolescents: a systematic review |journal=[[American Journal of Preventive Medicine]] |volume=35 |issue=3 |pages=287–313 |date=September 2008 |pmid=18692745 |doi=10.1016/j.amepre.2008.06.024 |url=https://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0026074 |archive-url=https://web.archive.org/web/20140203040225/http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0026074/ |url-status=live |archive-date=3 February 2014}}</ref> Repetitive play can also be one way a child relives traumatic events, and that can be a symptom of trauma in a child or young person.<ref name=Fletcher2003>{{cite book |veditors=Mash EJ |vauthors=Fletcher KE, Barkley RA |title=Child psychopathology |url=https://archive.org/details/childpsychopatho00mash_735 |url-access=limited |year=2003 |chapter=7 |publisher=[[Guilford Press]] |location=New York |isbn=978-1-57230-609-7 |pages=[https://archive.org/details/childpsychopatho00mash_735/page/n342 330]–371 |edition=2nd}}</ref> Although it is commonly used, there have not been enough studies comparing outcomes in groups of children receiving and not receiving [[play therapy]], so the effects of play therapy are not yet understood.<ref name=UK2005/><ref name=Wethington2008 />

==== Military programs ====
Many veterans of the wars in [[Iraq War|Iraq]] and [[War in Afghanistan (2001–present)|Afghanistan]] have faced significant physical, emotional, and relational disruptions. In response, the [[United States Marine Corps]] has instituted programs to assist them in re-adjusting to civilian life, especially in their relationships with spouses and loved ones, to help them communicate better and understand what the other has gone through.<ref name=Marriagetherapy>{{cite news |url=https://www.foxnews.com/story/marine-corps-offers-yoga-massages-to-marriages-strained-by-war |title=Marine Corps Offers Yoga, Massages to Marriages Strained by War |agency=Associated Press |date=2008-04-02 |access-date=2008-04-03 |work=[[Fox News]] |url-status=live |archive-url=https://web.archive.org/web/20080405164223/http://www.foxnews.com/story/0,2933,344991,00.html |archive-date=2008-04-05}}</ref> [[Walter Reed Army Institute of Research]] (WRAIR) developed the [[Battlemind]] program to assist service members avoid or ameliorate PTSD and related problems. [[Wounded Warrior Project]] partnered with the US Department of Veterans Affairs to create [[Warrior Care Network]], a national health system of PTSD treatment centers.<ref>{{Cite news |url=http://www.military.com/daily-news/2015/11/06/private-hospital-network-to-help-va-mental-health-care-vets.html |title=Private Hospital Network to Help VA with Mental Health Care for Vets |vauthors=Sweeney H |date=November 6, 2015 |work=Military.com |access-date=2017-03-29 |url-status=live |archive-url=https://web.archive.org/web/20170330085254/http://www.military.com/daily-news/2015/11/06/private-hospital-network-to-help-va-mental-health-care-vets.html |archive-date=March 30, 2017}}</ref><ref>{{Cite news |url=https://www.bostonglobe.com/metro/massachusetts/2016/05/02/changing-culture/CAjKLHyN6c5xobx8sdgKCO/story.html |title=Covering all the bases for veterans |vauthors=Cullen K |date=May 2, 2016 |work=[[The Boston Globe]]|access-date=2017-03-29 |url-status=live |archive-url=https://web.archive.org/web/20170330174306/https://www.bostonglobe.com/metro/massachusetts/2016/05/02/changing-culture/CAjKLHyN6c5xobx8sdgKCO/story.html |archive-date=March 30, 2017}}</ref>

==== Nightmares ====
In 2020, the United States [[Food and Drug Administration]] granted marketing approval for an [[Apple Watch]] app call NightWare. The app aims to improve sleep for people suffering from PTSD-related nightmares, by vibrating when it detects a nightmare in progress based on monitoring heart rate and body movement.<ref>{{cite web |url=https://kyma.com/videor/2020/11/11/fda-approves-apple-watch-app-nightware-to-treat-ptsd-nightmares/ |title=FDA approves Apple Watch app NightWare to treat PTSD nightmares |website=Kyma|date=11 November 2020 }}</ref>