Editing Post-traumatic stress disorder (section)

=== 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>