Exposure to at least one trauma is required for a diagnosis of PTSD. The latest version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) determines direct traumas as threatened death, actual or threatened serious injury, or actual or threatened sexual violence. Indirect traumas include witnessing the trauma, or learning that a relative or close friend was exposed to a trauma. Differences in trauma characteristics, along with differences in personal characteristics, may affect the risk of developing PTSD.

What is the evidence for abuse and violence and risk for PTSD?

Moderate to high quality evidence found a large association between exposure to sexual assault and subsequent PTSD-related conditions. There were medium-sized increases in PTSD symptoms following exposure to bullying, racism, and childhood sexual or physical abuse. There were no significant associations between PTSD and neglect or witnessing interpersonal violence in childhood.

Moderate quality evidence found a medium-sized association between victimisation from intimate partner violence and PTSD, and a small association between perpetration of intimate partner violence and PTSD. These associations were similar for males and females.

Moderate to high quality evidence found a small association between greater level of exposure to mass shootings (closer proximity, longer duration) and increased PTSD symptoms in those exposed.

August 2021

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Pending enough primary studies, we invite reviews on this topic to be conducted. Alternatively we will endeavour to conduct our own review to fill this gap in the Library.

October 2021

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Acupuncture is practiced as an accepted health care model in China, Korea and Japan. Traditionally, it involves the stimulation of specific points (acupoints) by inserting needles into the skin. Electro-acupuncture is similar in that the same points are stimulated with needles inserted on specific points along the body. It uses two needles attached to an electrical device that generates continuous electric pulses. These pass from one needle to the other with varying frequency and intensity dictated by the condition. Administration is usually for no more than 30 minutes at a time. Laser acupuncture is essentially the same except that a laser is used instead of needles. Moxibustion uses heat from burning a herb (artemisia vulgaris), or uses an electric source, to stimulate specific points or areas of the body.

One of the challenges in performing efficacy trials of acupuncture is that it is difficult to provide a control condition. Sham methods that have been used include needling the wrong points or with very superficial technique. Or using a simulation of laser acupuncture without full stimulation.

What is the evidence for the effectiveness of acupuncture in people with PTSD?

Moderate to low quality evidence found improvements in PTSD symptoms and some improvement in depression symptoms and functioning following needle acupuncture (30 to 60 minutes per session, 2 to 4 sessions per week over 3 to 12 weeks). There were no improvements in anxiety, sleep, or quality of life. Some participants experienced minor to moderate pain, superficial bleeding, and hematoma at needle insertion sites.

August 2021

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Personal characteristics, such as age, can influence one’s degree of risk for developing post-traumatic stress disorder. How such personal characteristics may affect the development of PTSD would be influenced by other personal characteristics as well as differences in the trauma experience itself.

What is the evidence for effects of age on risk for PTSD?

Moderate to high quality evidence found small associations between younger age and more PTSD symptoms in women following childbirth, and in professionals indirectly exposed to trauma through their therapeutic work with trauma victims. Moderate quality evidence found small associations between older age and more symptoms following burn injuries, and following earthquakes.

There was a medium-sized effect of more PTSD symptoms in older adults (>60-65 years) than younger adults (<60 years) following exposure to any natural disaster. However, there was also a medium-sized effect of less severe PTSD symptoms in older adults following exposure to any man-made disaster. Review authors suggest the disparity in findings between natural and human-induced disasters may be explained by older adults being less likely to receive advanced warnings or to evacuate during a natural disaster, and therefore may experience greater disruption or perceived loss, while previous experiences may better prepare older people to cope with man-made disasters.

There were no effects of age on risk of PTSD after a fall in elderly people (age 65 to 90 compared to over 90 years), following a traumatic brain injury at any age, and in combat-exposed military personnel and veterans.

August 2021

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Scientific understanding of the neurobiological changes occurring during PTSD onset shows memory consolidation appears particularly vulnerable to disruption in the first six hours after trauma, making this a crucial period for intervention for prevention of PTSD. This technical commentary presents the evidence on pharmaceutical interventions administered during this period. Please also see the psychotherapy for prevention of PTSD topic.

What is the evidence on medications for the prevention of PTSD?

Hydrocortisone is a glucocorticoid, which attenuates heightened fear response through increased removal of fear-inducing memories. Moderate to low quality evidence found a medium to large, reduced risk of PTSD within 3-6 months post-trauma in people with severe physical illness or injury receiving hydrocortisone post-trauma. Risks were not assessed in these samples, so contraindications need checking.

There was no benefit of hydrocortisone over placebo after 6 months post-trauma. There were also no benefits of propranolol, oxytocin, gabapentin, fish oil, dexamethasone, escitalopram, imipramine, or chloral hydrate for preventing PTSD at any time frame. Studies are few and small.

August 2021

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Several beneficial treatments for PTSD are available, including pharmaceutical and psychological approaches. Treatment guidelines typically recommend psychological therapies as first-line PTSD treatment. However, some antidepressants in particular may also be used as first-line treatment. It remains uncertain whether benefit increases when combining pharmacological and psychological treatments. This topic presents the evidence for all pharmaceutical treatments compared to all psychosocial and combination therapies for PTSD.

What is the evidence on pharmaceutical versus psychological and combination interventions for PTSD?

Moderate to low quality evidence found large improvements in PTSD symptoms by last follow-up with psychotherapy and with psychotherapy + medication compared to medications alone. There were no differences between these three treatment options immediately following treatment, and no differences between combined and psychological therapies at last follow-up. There were no differences in drop-outs rates, indicating similar tolerability of all treatments.

Note that last follow-up time frames were not reported in the reviewed evidence, and treatments were not all necessarily maintained to last follow-up, so these results must be interpreted with caution.

August 2021

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Treatment guidelines typically recommend psychological treatments as first-line treatment for PTSD. Cognitive behavioural therapy (CBT) is one of the most common psychological treatments. CBT challenges distorted, negative thinking patterns associated with the trauma to help people develop more adaptive cognitions and behaviours. It also assists people to rethink assumptions and reactions to the event. Exposure therapies aim to desensitise people to trauma-related memories. This helps overcome symptoms by exposure to specific or non-specific cues or memories related to the trauma. Eye movement desensitisation and reprocessing (EMDR) involves the patient focussing on a disturbing image, memory, emotion, or cognition associated with the trauma while the therapist initiates rapid voluntary eye movements. This is based on the observation that the intensity of traumatic memories can be reduced through eye movements, although how this occurs remain unclear. Other common therapies include narrative therapy, which can help people reconstruct a consistent narrative about the trauma, and supportive therapy, which involves giving support, listening, and helping.

What is the evidence for psychotherapy for PTSD?

Moderate to low quality evidence found large improvements in PTSD symptoms for up to 20 months after treatment with any psychological and combined psychological plus medication treatments compared to medications alone. These improvements were largest in military samples and in people exposed to childhood abuse.

There were large improvements in PTSD symptoms, depression, and anxiety for up to four weeks post-treatment with psychological therapies in adults exposed to humanitarian crises in low and middle-income countries. Smaller, but significant improvements were found for up to 6 months. There were improvements in children in these settings, particularly in children aged 15-18 years, in non-displaced children, and in children living in smaller households (<6 members). Functioning, hope, coping, and social support also improved. There were no improvements in depression and anxiety post-treatment and at follow up (≥6 weeks) in children in these settings.

Moderate quality evidence found CBT with or without a trauma focus, EMDR, prolonged exposure, cognitive processing therapy, narrative exposure therapy, cognitive therapy, present-centred therapy, and virtual reality therapy all showed greater improvements in PTSD symptoms than waitlist or treatment as usual. Moderate to low quality evidence found CBT with a trauma focus was more effective for PTSD symptoms than present-centred therapy, supportive counselling, relaxation training, dialogical exposure therapy, and interpersonal therapy.

August 2021

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Alpha blockers, such as prazosin, are medications that work as alpha-adrenergic receptor antagonists. They cross the blood-brain barrier, antagonise the alpha receptors in the central nervous system, and block the stress response. Higher than normal nocturnal central nervous system adrenergic activity that occurs in PTSD contributes to the disruption of normal rapid eye movement sleep. Prazosin reduces this adrenergic activity and therefore could be effective in treating posttraumatic arousal symptoms such as sleep disturbances and nightmares.

What is the evidence on prazosin for PTSD?

Moderate quality evidence found medium to large improvements in PTSD symptoms, nightmares, and sleep disturbances with prazosin than with placebo when compared at treatment endpoint. When comparing baseline to endpoint improvements over time, there was also a large reduction in nightmare frequency, and a trend, medium-sized improvement in PTSD symptoms with prazosin. However, there were no significant differences in sleep quality between prazosin and placebo, suggesting the placebo group may have had more sleep disturbances at baseline (the two reviews in this topic included mostly the same studies).

Prazosin resulted in more dry mouth than placebo, with no differences in dizziness, headache, nausea, lack of energy, muscle weakness or asthenia, drowsiness or somnolence, syncope, nasal congestion, or palpitations.

August 2021

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Excessive anger is often observed in people with PTSD and other anxiety-related disorders. In PTSD, a propensity towards excessive anger may be apparent before exposure to a trauma, for example as a personality trait. Or it could be a result of exposure to the trauma itself and a symptom of PTSD. Elevated anger in people with PTSD has clinical implications as it may be a barrier to effective treatment outcomes. Therefore, anger and aggression are key targets for improvement early in the treatment process.

What is the evidence for anger and aggression in people with PTSD?

Moderate to high quality evidence finds a large increase in difficulty with anger in people with PTSD than in people without PTSD. There were high levels of anger and hostility in veterans, police, and firefighters prior to exposure to trauma and development of PTSD.

In veterans post-deployment, the overall prevalence of any aggressive behaviour is around 36%, which is significantly higher than in veterans who have not had combat exposure. Veterans deployed to combat situations who subsequently develop PTSD show the highest levels of aggressive behaviour, particularly if they also misuse alcohol.

August 2021

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Animal-assisted psychotherapy is a goal-directed intervention involving an animal as part of the treatment process. It is usually delivered by a health service professional with specialised expertise and is designed to improve mental and physical health. Studies have shown that being around animals can decrease blood pressure, physiological arousal, and cardiopulmonary pressure. It may also improve trauma symptoms.

What is the evidence for animal-assisted psychotherapy?

Moderate to low quality evidence found a large improvement in PTSD, depression, and anxiety symptoms with animal-assisted therapy (pre-post analysis, mostly utilising group sessions with horses). The effect was medium-sized when compared to control conditions. The following factors were associated with largest effects; studies conducted in Australia (rather than the US or Spain), the intervention provider was someone other than a psychologist, psychiatrist, or therapist, interventions with additional in-clinic individual therapy, studies with more women, group interventions, and interventions delivered outside.

August 2021

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