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Posttraumatic Stress Disorder
Introduction
Posttraumatic stress disorder (PTSD) is a stress response that has become overwhelming, prolonged, and incapacitating from exposure to a traumatic event.1 Traumatic events can be short-lived or ongoing and can be experienced first-hand or by witnessing or learning about an event. Examples of traumatic events include enduring severe bodily injury, combat, torture, terrorism, serious motor-vehicle accidents, man-made or natural disasters, assault, rape, abuse, or major illness.1,2 Other examples may include witnessing such events, or learning about an injury or death of a loved one.1 Characteristic symptoms of PTSD include (1) reactions of fear, hopelessness, or horror; (2) persistent event-related thoughts or dreams; (3) avoidance of event reminders with feelings of detachment; (4) persistent edginess or hypervigilance; and (5) resultant impairment in the activities of daily living.1 While the diagnosis of PTSD requires the presence of symptoms for at least 1 month, both the onset and duration of symptoms can vary widely across individuals.1 In the United States, the lifetime prevalence of PTSD among adults is estimated to be approximately 8 percent.1 However, PTSD is a worldwide problem, and it can occur at any age.
Interventions for the treatment of PTSD most commonly include the use of psychotherapies, pharmacotherapies, or combinations of both. By summarizing the evidence gained from systematic reviews, this report focuses on psychological interventions and their efficacy in reducing or preventing PTSD symptomatology in vulnerable populations affected by trauma. Interventions in the report range from those focusing on treating PTSD symptoms, such as exposure therapy, to those administered within 1 to 3 months following exposure to trauma with the specific intent of preventing PTSD, such as debriefing interventions and trauma-focused cognitive behavioral therapy (TF-CBT).
Search Strategy and Criteria
An extensive search was conducted for systematic reviews. The search was limited to the online catalog of the U.S. Government’s National Library of Medicine, PubMed to ensure free access to abstracts, and in some cases, full-text articles. Systematic reviews reported in the context of guidelines, consensus statements, or studies were not the target of the search.
The strategy used to conduct the search appears below and consists of several parts: ("Stress Disorders, Traumatic/therapy"[Majr] OR "Stress Disorders, Traumatic/prevention and control"[Majr] OR "Stress Disorders, Traumatic/rehabilitation"[Majr]) AND (systematic[sb] OR Meta-Analysis[pt]) AND “English”[lang] AND “Humans”[MeSH Terms] AND [PDAT]: [PDAT]
Each part of the strategy is described below:
- Topics: The following PubMed medical subjects headings were used to limit the search to prevention or treatment of PTSD symptomatology: "Stress Disorders, Traumatic/therapy"[Majr] OR "Stress Disorders, Traumatic/prevention and control"[Majr] OR "Stress Disorders, Traumatic/rehabilitation"[Majr]).
- Additional limits: Limits were used restricting the search to systematic reviews (with a separate designation for those containing meta-analyses) and articles published in English, focusing on humans.
Results
The literature search yielded a total of 26 systematic reviews assessing the effectiveness of psychological interventions aimed at preventing or reducing PTSD symptoms. Of the 26 systematic reviews, 18 included a meta-analysis (Reviews 1, 2, 5, 7–12, 15, 17–20, 22, 23, 25, 26). The average number of studies included in a systematic review was 21 (median = 19). Studies were conducted in the United States and internationally. Most studies did not specify the settings where the psychological interventions were carried out; however, for those that reported, settings included refugee camps, torture and trauma clinics, university-based clinics, inpatient and outpatient facilities, and Veterans Administration (VA) settings. The study populations consisted of participants with PTSD symptoms as a result of trauma (e.g., combat, motor-vehicle accidents, sexual assault, terrorism, HIV-positive diagnosis). The objective of most systematic reviews was to examine whether psychological interventions are effective in the treatment of PTSD, and if so, whether certain psychological interventions are more effective than others in reducing PTSD symptoms. Psychological interventions assessed in these systematic reviews include cognitive behavioral therapy (CBT), eye movement desensitization and reprocessing (EMDR), narrative exposure therapy (NET), stress inoculation therapy (SIT), TF-CBT, prolonged exposure (PE) therapy, and interpersonal psychotherapy. Other systematic reviews assessed the effectiveness of PTSD prevention interventions in individuals exhibiting PTSD symptoms (Reviews 11, 16, 17, 20, 25). As a secondary goal, some of the systematic reviews examined whether intervention efficacy varied by treatment population or type of trauma (Reviews 9, 22, 26).
The findings across all systematic reviews demonstrate that PTSD symptoms are reduced as a result of psychological interventions. Although most of the systematic reviews intended to compare different psychological interventions in their effectiveness of treating PTSD symptoms, the heterogeneity of data made this difficult. However, CBT emerged as more effective than non–CBT-based interventions in one systematic review, and CBT consistently emerged as an effective intervention compared to wait-list controls or participants undergoing treatment as usual.
PTSD Treatment in Children
Seven systematic reviews focused on children and adolescents with PTSD symptoms (Reviews 12, 15, 18, 19, 22, 24, 26). Five of the seven systematic reviews examining children and adolescents reported CBT as effective in treating PTSD symptoms in children and adolescents. One review found a small but significant difference in favor of EMDR therapy over CBT in treating PTSD symptoms in youth aged 18 and younger. Findings on intervention effects and trauma type for children were mixed. One review found children who experienced sexual abuse demonstrated the largest change in posttraumatic stress symptoms, while another review found the effects of intervention were larger for children who experienced types of trauma other than sexual abuse.
PTSD Treatment in Adults
The remaining 19 systematic reviews focused on adults with PTSD symptoms. Eleven systematic reviews specifically assessed only adults who met the DSM-III or DSM-IV diagnostic criteria for PTSD (Reviews 1–5, 7–9, 10, 16, 23). Type of trauma emerged as a significant moderator of intervention effects. In particular, one systematic review found that adults who experienced assault demonstrated the greatest change in PTSD symptoms from pre- to posttest. Gender also emerged as a moderator. Specifically, there was evidence to suggest females responded better to TF-CBT than males. Systematic reviews examining the effect of psychological interventions on the prevention of PTSD found that TF-CBT interventions administered within 3 months of a traumatic event are effective in preventing PTSD, but debriefing interventions, administered within 1 month of a traumatic event were not effective in preventing PTSD.
Overall, there is strong evidence that psychological interventions are effective in reducing, but not preventing, PTSD symptoms in children, adolescents, and adults. Although CBT most frequently emerged as a successful intervention, there is limited evidence to suggest one form of psychological intervention is significantly better than another.