Adult survivors of childhood abuse tend to have more symptom complexity than other adults with PTSD. This complexity includes emotion dysregulation, interpersonal problems, impulsive and/or self-destructive behaviour, high levels of dissociation, substance-related problems, and unexplained physical symptoms.

For PTSD in general, the best evidence currently exists for trauma-focussed treatments such as cognitive behaviour therapy (CBT), exposure therapy, and eye movement desensitisation and reprocessing (EMDR). These interventions involve processing the memory of the trauma and its meaning based on theoretical models that emphasise the role of memory processes in the development and maintenance of PTSD. However, it is unclear whether the superiority of trauma-focused treatments holds for adult survivors of child-onset trauma or whether trauma-focussed treatments may even be damaging to these patients.

What is the evidence for psychotherapy for PTSD in people with a history of childhood abuse?

Moderate to low quality evidence found a large improvement in PTSD symptoms with active psychological treatments (CBT with or without trauma-focus, EMDR, interpersonal therapy, and emotion-focussed therapies) from before to after treatment and at longer-term follow-up (≥6 months) in adults with a history of childhood abuse. These improvements were larger than those observed in the pre-post analyses of no treatment controls and inactive treatment controls (e.g., treatment as usual).

In the direct comparisons of symptom severity immediately post-treatment with active treatments versus control conditions, the comparison with no treatment controls showed a significant, medium to large effect of greater improvements. However, the direct comparison with inactive treatment showed a non-significant medium-sized effect. Trauma-focussed treatments were found to be more efficacious than non-trauma-focussed interventions, and treatments with individual sessions were more efficacious than group treatments. Samples with complex PTSD showed smaller improvements than samples without complex PTSD.

August 2021

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Traumatic events are highly prevalent in childhood and adolescence. PTSD is often chronic and has immense personal and social costs, and the prognosis for recovery without adequate treatment is poor. Therefore, early and effective treatment is important.

What is the evidence for psychotherapy for PTSD in children and adolescents?

Moderate quality evidence found a large improvement in PTSD symptoms with psychological treatments by the end of treatment, and a medium-sized improvement by six months post-treatment when compared to untreated or waitlist controls. Compared to treatment as usual or active controls, there were small to medium-sized improvements in PTSD symptoms by the end of treatment and by six months post-treatment. Depression and anxiety symptoms also improved, although to a lesser extent. Studies with older patients, more females, and higher-quality studies reported the largest effect sizes. Individual treatments showed larger effect sizes than group treatments. Treatments that involved caretakers showed larger effect sizes than those involving children/adolescents alone. Studies with more treatment time reported larger effect sizes than shorter treatments. School-based therapies were also effective. There were no influencing effects of trauma type on PTSD symptom outcomes.

For individual psychological therapies compared to waitlist/no treatment, moderate to low quality evidence found the following therapies were effective (in descending order of effect); cognitive therapy for PTSD (individual trauma-focussed cognitive behavioural therapy [CBT]), combined somatic/cognitive therapies, child-parent psychotherapy, combined trauma-focussed CBT plus parent training, meditation, narrative exposure, exposure/prolonged exposure, play therapy, Cohen trauma-focussed CBT/cognitive processing therapy, and eye movement desensitisation reprocessing [EMDR]. At 1-4 months post-treatment, combined somatic/cognitive therapies, Cohen trauma-focussed CBT/cognitive processing therapy, combined trauma-focussed CBT plus parent training, and narrative exposure all continued to show large effects. There were no significant improvements in symptoms with parent training alone, supportive counselling, or family therapy. Cognitive therapy for PTSD was the most cost-effective intervention, followed by narrative exposure, EMDR, parent training, and group trauma-focussed CBT. Family therapy and supportive counselling were the least cost-effective options.

For children in low and middle-income countries, moderate to low quality evidence found improvements in PTSD symptoms post-treatment with any psychosocial therapy and at follow up (up to one year). Most improvements were found in the children aged 15-18 years, in non-displaced children, and in children living in smaller households (<6 members). Depression, functioning, hope, coping, and social support also improved. There was a strong relationship between improvements in functioning and improvements in PTSD symptoms. Interventions delivered by trained, non-specialist lay health workers in schools improved PTSD symptoms, depression, and functioning.

August 2021

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Complex PTSD can arise from chronic violence or abuse. It includes the core symptoms of PTSD plus disturbances in self organisation, affect dysregulation, negative self-concept, and relationships. People with complex PTSD may also show high levels of depression, psychological distress, dissociation, and substance misuse.

What is the evidence for psychotherapy for complex PTSD?

Moderate to low quality evidence found large improvements in PTSD symptoms after psychological treatments in women with a history of childhood abuse. The effect was medium sized in women with complex PTSD and large in women with non-complex PTSD when compared to usual care or waitlist conditions.

Moderate quality evidence found a medium-sized improvement in PTSD symptoms with group-based trauma interventions compared to usual care in people with complex PTSD and a history of interpersonal trauma or abuse. Both specific-to-trauma and non-specific-to-trauma treatments improved PTSD symptoms in people with complex and non-complex PTSD. This effect was greatest with specific-to-trauma interventions, and in people with non-complex PTSD.

For individual psychological therapies, moderate quality evidence found cognitive behavioural therapy (CBT), exposure therapy, and eye movement desensitisation reprocessing (EMDR) all improved PTSD symptoms in people with complex PTSD when compared to standard care/waitlist (all large effects). CBT, exposure therapy, and EMDR also improved disturbances in relationships, affect dysregulation, and negative self-concept when compared to standard care/waitlist (all medium to large effects). Only CBT and EMDR improved PTSD symptoms when compared to non-specific therapies (medium-sized effects). Only CBT improved relationships (small to medium-sized effect), and only EMDR improved negative self-concept (medium to large effect) when compared to non-specific therapies.

August 2021

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Dual diagnosis describes a condition when a person with both a mental health diagnosis such as PTSD and a substance use disorder. This comorbidity is associated with poorer treatment outcomes than for either condition alone. Several psychological therapies are successful at treating each disorder individually, however when occurring together, they may be harder to treat.

What is the evidence for psychotherapy for dual diagnosis?

Moderate to low quality evidence found a small improvement in PTSD symptoms in people with a dual diagnosis following individual psychological treatments that have a trauma focus when compared to treatment as usual. This effect remained for up to seven months. There was also a small reduction in substance use with individual psychological therapy with a trauma-focus at 5 to 7 months follow-up, but not immediately following treatment. The only other significant improvement in substance use was with a full dose of a group therapy called Seeking Safety. This was found immediately post-treatment but not at follow-up. There were no significant benefits for PTSD symptoms or substance use with non-trauma-based treatments or with other group treatments.

August 2021

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Many people living in low- or middle-income countries are exposed to adversities, such as conflict and war. In developing countries, most people with PTSD do not receive adequate care. This is due to insufficient mental health services and challenges in implementing evidence-based interventions. Non-specialist health workers and other professionals such as teachers have an important role in delivering mental health care in these settings.

What is the evidence on effectiveness of psychotherapy for PTSD in low- and middle-income countries?

Moderate to low quality evidence found large improvements in PTSD symptoms, depression, and anxiety for up to four weeks following treatment with psychological therapies in adults exposed to humanitarian crises in low-resource settings.. Therapies included trauma-focussed or supportive therapies, eye movement desensitisation and reprocessing, cognitive behavioural therapy, and interpersonal psychotherapy. There were smaller, but significant improvements for up to six months.

There were also improvements in children in these settings following focussed psychological therapies, particularly in children aged 15-18 years, in non-displaced children, and in children living in small households (<6 members). Functioning, hope, coping, and social support also improved, although only improvements in functioning helped improve PTSD symptoms. There were no significant improvements in depression and anxiety immediately post-treatment and at short-term follow up (6 weeks).

Moderate quality evidence found a large improvement in PTSD symptoms with active psychological treatments immediately following treatment and at follow-up (up to 24 months) in child and adult survivors of mass violence in low- and middle-income countries. The effects were smaller, but remained significant, when compared to control conditions. Depression and functioning also improved.

For non-specialist, lay health worker interventions in low- and middle-income countries, moderate to low quality evidence found a small improvement in PTSD symptoms in adults, and a large improvement in PTSD symptoms in children and adolescents at around six months post-treatment. Children and adolescents also showed improvements in functioning and depression.

Moderate quality evidence found no differences in PTSD symptoms following psychological therapies for women exposed to intimate partner violence compared to women not exposed to intimate partner violence in low- and middle-income countries. Only anxiety improved in exposed women.

August 2021

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Early intervention models suggest psychological interventions given to an individual exposed to a traumatic event may prevent the onset of trauma-related symptoms.

Cognitive therapies are based on the theory that an individual’s perception of a situation influences his or her emotional response to it. They aim to help people identify distorted thinking and to modify existing beliefs. Cognitive processing therapy is a type of cognitive therapy that involves psychoeducation, written accounts about the traumatic event, and cognitive restructuring to address beliefs about the event’s meaning and its implications.

Cognitive behavioural therapy (CBT) is one of the most common psychological treatments that are effective for the treatment of PTSD. CBT challenges distorted, negative thinking patterns associated with the trauma. It aims to help people develop more adaptive cognitions and behaviours, and to rethink assumptions and reactions to the event.

Exposure therapies to desensitise people to trauma-related memories by exposing them to specific and non-specific cues 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 the underlying mechanisms remain unclear.

Other therapies include narrative therapy, which can be used to help people reconstruct a consistent narrative about the trauma. Psychoeducation may help normalise stress reactions. Psychodynamic therapy can help people process the trauma emotionally and gain a better understanding of their responses to it. Supportive therapy involves counsellors giving support, listening, and helping people talk over their problems. Family therapy focusses on improving family communication and functioning.

What is the evidence on effectiveness of psychotherapy for prevention of PTSD?

Moderate quality evidence found a medium-sized reduction in rates of PTSD diagnosis, and more improvement in PTSD symptoms for up to one month following psychological therapy (mostly CBT) in children and adolescents exposed to trauma. However, these effects were not significant over the longer term. Direct comparisons between interventions showed no differences in rates of PTSD diagnosis in children receiving CBT, EMDR, or supportive therapy. However, CBT was better than EMDR, play therapy, and supportive therapy for PTSD symptom improvement.

There was a small reduction in PTSD diagnoses in adults exposed to trauma by 3-6 months following multiple-session, early psychological interventions. However, there were no differences immediately post-treatment or at 7-12 months after treatment. There were also no differences in PTSD symptom severity, depression, anxiety, or quality of life. Authors report a high risk of bias in the included trials.

August 2021

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Over the past two decades, the number of forcibly displaced migrants has grown due to ongoing conflicts in countries around the world. Compared to the general population, refugees experience considerably higher levels of psychological distress due to major losses and exposure to events such as torture and war. Post-displacement stressors are also apparent, including those associated with resettlement, language barriers, and perceived stigma and discrimination. Any of these trauma exposures can contribute to higher rates of mental health conditions, including PTSD, depression, and anxiety.

What is the evidence on psychotherapy for PTSD in refugees and asylum seekers?

Moderate quality evidence found a medium to large effect of improved PTSD symptoms with psychological therapies, particularly CBT with a trauma-focussed component, when compared to waitlist, treatment as usual, or no treatment. Depression and anxiety symptoms also improved with psychological therapies. These outcomes were maintained post-treatment (1-18 months). There were no differences in effectiveness for PTSD symptoms between individual and group interventions.

August 2021

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Soldiers and veterans have exposure to life threatening stressors, including combat, injury, and witnessing suffering and death. These traumatic combat experiences are often less straightforward than single traumatic events, and may decrease PTSD treatment effectiveness. Interventions that may be effective for PTSD in soldiers and veterans include eye movement desensitisation and reprocessing, exposure therapy, cognitive therapy, cognitive restructuring therapy, cognitive processing therapy, trauma-focused cognitive behavioural therapy, and stress management.

What is the evidence on psychotherapy for PTSD symptoms in soldiers and veterans?

Moderate to low quality evidence found large improvements in PTSD symptoms in military and veteran samples following treatment with psychological therapies. Treatments involving more trauma-focussed sessions were most effective, and exposure therapies were more effective than stress management. Individual therapies were more effective than group therapies. Veterans with particularly low or high pre-treatment symptom severity showed less symptom improvement than veterans with moderate pre-treatment symptom severity.

August 2021

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