EFFECTIVE TREATMENTS FOR PTSD

Effective Treatments for

PTSD
Practice Guidelines from
the International Society
for Traumatic Stress Studies
THIRD EDITION

edited by
David Forbes
Jonathan I. Bisson
Candice M. Monson
Lucy Berliner

THE GUILFORD PRESS

New York  London
Copyright © 2020 The Guilford Press
A Division of Guilford Publications, Inc.
370 Seventh Avenue, Suite 1200, New York, NY 10001
www.guilford.com

Chapter 6, ISTSS PTSD Prevention and Treatment Guidelines:

Methodology, and Chapter 7, ISTSS PTSD Prevention and Treatment
Guidelines: Recommendations, Copyright © 2020 International Society for
Traumatic Stress Studies

All rights reserved

No part of this book may be reproduced, translated, stored in a retrieval

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Printed in the United States of America

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Last digit is print number: 9 8 7 6 5 4 3 2 1

Library of Congress Cataloging-in-Publication Data

Names: Forbes, David (Clinical psychologist), editor.
Title: Effective treatments for PTSD : practice guidelines from the
International Society for Traumatic Stress Studies / edited by
David Forbes, Jonathan I. Bisson, Candice M. Monson, Lucy Berliner.
Description: Third edition. | New York : The Guilford Press, [2020] |
Includes bibliographical references and index.
Identifiers: LCCN 2019056124 | ISBN 9781462543564 (paperback) |
ISBN 9781462543571 (hardback)
Subjects: LCSH: Post-traumatic stress disorder—Treatment—Standards. |
Psychic trauma—Treatment—Standards. | Psychotherapy—Standards.
Classification: LCC RC552.P67 E35 2020 | DDC 616.85/21—dc23
LC record available at https://lccn.loc.gov/2019056124
About the Editors

David Forbes, PhD, is Director of Phoenix Australia Centre for Posttrau-

matic Mental Health and Professor in the Department of Psychiatry at the
University of Melbourne. He began practicing as a clinical psychologist in
the mid-1990s and has a strong research track record in the assessment and
treatment of mental health problems in trauma survivors, with a speciality
in military, veteran, emergency services, and post-disaster mental health.
Dr. Forbes led the development of the Australian Guidelines for the Treat-
ment of Acute Stress Disorder and PTSD and is Co-Chair of the 5-Eyes Men-
tal Health Research and Innovation Collaboration.

Jonathan I. Bisson, DM, FRCPsych, is Professor of Psychiatry at Cardiff

University School of Medicine, Wales, United Kingdom, and a practicing
psychiatrist. He is Chair of the Treatment Guidelines Committee of the
International Society for Traumatic Stress Studies and is currently develop-
ing an All Wales Traumatic Stress Quality Improvement Initiative. Dr. Bis-
son was Co-Chair of the first PTSD Guideline Development Group of the
United Kingdom’s National Institute for Health and Care Excellence. He is
a past president of the European Society for Traumatic Stress Studies and
led the development of Veterans NHS Wales. He has conducted widely cited
research on the prevention and treatment of PTSD.

Candice M. Monson, PhD, is Professor of Psychology at Ryerson University

in Toronto, Ontario, Canada. She is President-Elect of the International Soci-
ety for Traumatic Stress Studies and is a Fellow of the American and Cana-
dian Psychological Associations, the Association for Behavioral and Cogni-
tive Therapies, and the Royal Society of Canada. Dr. Monson is a foremost

v
vi About the Editors

expert on traumatic stress and the use of individual and conjoint therapies
to treat PTSD. She is coauthor of Cognitive Processing Therapy for PTSD and
Cognitive-Behavioral Conjoint Therapy for PTSD and coeditor of Effective Treat-
ments for PTSD, Third Edition, among other books.

Lucy Berliner, MSW, is Director of the Harborview Center for Sexual

Assault and Traumatic Stress at the University of Washington, where she
is also Clinical Associate Professor in the School of Social Work and in the
Department of Psychiatry and Behavioral Sciences. Her activities include
clinical practice with child and adult victims of trauma and crime; research
on the impact of trauma and the effectiveness of clinical and societal inter-
ventions; and participation in local and national social policy initiatives to
promote the interests of trauma and crime victims.
Contributors

Eva Alisic, PhD, Child and Community Wellbeing Unit, School of Population
and Global Health, University of Melbourne, Melbourne, Australia
Sudie E. Back, PhD, Department of Psychiatry and Behavioral Sciences,
Medical University of South Carolina, Charleston, South Carolina
Lucy Berliner, MSW, Harborview Abuse and Trauma Center, Seattle, Washington
Jonathan I. Bisson, DM, FRCPsych, Department of Psychological Medicine
and Clinical Neurosciences, School of Medicine, Cardiff University,
Cardiff, Wales, United Kingdom
Chris R. Brewin, PhD, Department of Clinical, Educational, and Health Psychology,
University College London, London, United Kingdom
Richard A. Bryant, PhD, School of Psychology, University of New South Wales,
Sydney, Australia
Mark Burton, PhD, Department of Psychiatry and Behavioral Sciences,
Emory University School of Medicine, Atlanta, Georgia
Kathleen M. Chard, PhD, Trauma Recovery Center, Cincinnati VA Medical Center
and Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati,
Cincinnati, Ohio
Kelly Chrestman, PhD, Center for Deployment Psychology, Department of Medical
and Clinical Psychology, Uniformed Services University of the Health Sciences,
Bethesda, Maryland
Marylene Cloitre, PhD, National Center for PTSD, Palo Alto VA Health Care
Services, Palo Alto, California; Department of Psychiatry and Behavioral Sciences,
Stanford University, Stanford, California
Judith Cohen, MD, Department of Psychiatry, Drexel University College of Medicine,
Pittsburgh, Pennsylvania
Zachary Cohen, PhD, National Center for PTSD, Palo Alto, California; Department
of Psychiatry, University of California, Los Angeles, Los Angeles, California
Rowena Conroy, PhD, School of Psychological Sciences, University of Melbourne,
Melbourne, Australia

vii
viii Contributors

Andrea Danese, MD, PhD, Department of Child and Adolescent Psychiatry,

Institute of Psychiatry, Psychology and Neuroscience, King’s College London,
London, United Kingdom
JoAnn Difede, PhD, Department of Psychology, Weill Cornell Medicine,
New York, New York
Shannon Dorsey, PhD, Department of Psychology, University of Washington,
Seattle, Washington
Grete Dyb, MD, PhD, Norwegian Centre for Violence and Traumatic Stress Studies
and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
Anke Ehlers, PhD, Oxford Centre for Anxiety Disorders and Trauma, Department
of Experimental Psychology, University of Oxford, Oxford, United Kingdom
Edna B. Foa, PhD, Center for the Study and Treatment of Anxiety, Department
of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania
David Forbes, PhD, Phoenix Australia Centre for Posttraumatic Mental Health
and Department of Psychiatry, University of Melbourne, Melbourne, Australia
Julian D. Ford, PhD, ABPP, Center for Trauma Recovery and Juvenile Justice,
Center for the Treatment of Developmental Trauma Disorders, and Department
of Psychiatry, University of Connecticut Health Center, Farmington, Connecticut
Tara E. Galovski, PhD, National Center for PTSD, VA Boston Healthcare System,
and Department of Psychiatry, Boston University School of Medicine,
Boston, Massachusetts
Jaimie Gradus, DSc, MPH, Department of Epidemiology, Boston University School
of Public Health; and Department of Psychiatry, Boston University School
of Medicine, Boston, Massachusetts
Mathew D. Hoskins, MBBCh, MSc, MRCPsych, Division of Psychological Medicine
and Clinical Neurosciences, School of Medicine, Cardiff University,
Cardiff, Wales, United Kingdom
Lisa Jaycox, PhD, RAND Corporation, Arlington, Virginia
Tine Jensen, PhD, Department of Psychology, University of Oslo, and Norwegian
Centre for Violence and Traumatic Stress Studies, Oslo, Norway
Tammy Jiang, MPH, Department of Epidemiology, Boston University School
of Public Health, Boston, Massachusetts
Thanos Karatzias, PhD, School of Health and Social Care, Edinburgh Napier
University, and NHS Lothian Rivers Centre for Traumatic Stress,
Edinburgh, United Kingdom
Nancy Kassam-Adams, PhD, Department of Pediatrics, University
of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
Debra L. Kaysen, PhD, Department of Psychiatry and Behavioral Sciences,
Stanford University Medical Center, Palo Alto, California
Justin Kenardy, PhD, School of Psychology, University of Queensland,
Queensland, Australia
Karestan C. Koenen, PhD, Departments of Epidemiology and Social
and Behavioral Sciences, Harvard T. H. Chan School of Public Health,
Cambridge, Massachusetts
Contributors ix

Kristina J. Korte, PhD, Department of Psychiatry, Massachusetts General Hospital,

Boston, Massachusetts
Ariel J. Lang, PhD, MPH, VA San Diego Center for Excellence for Stress
and Mental Health and Departments of Psychiatry and Family Medicine
and Public Health, University of California, San Diego, San Diego, California
Christopher Lee, PhD, Faculty of Health and Medical Sciences, University
of Western Australia, Perth, Australia
Catrin Lewis, PhD, Division of Psychological Medicine and Clinical Neurosciences,
School of Medicine, Cardiff University, Cardiff, Wales, United Kingdom
Andreas Maercker, MD, PhD, Department of Psychopathology and Clinical
Intervention, University of Zurich, Zurich, Switzerland
Sybil Mallonee, PhD, Department of Medical and Clinical Psychology, Uniformed
Services University of the Health Sciences, Bethesda, Maryland
Jessica Maples-Keller, PhD, Department of Psychiatry and Behavioral Sciences,
Emory University School of Medicine, Atlanta, Georgia
Ifigeneia Mavranezouli, MD, Research Department of Clinical, Educational
and Health Psychology, University College London, London, United Kingdom
Richard Meiser-Stedman, PhD, Department of Clinical Psychology
and Psychological Therapies, University of East Anglia, Norwich, United Kingdom
Cathrine Mihalopoulos, PhD, School of Health and Social Development,
Deakin University, Geelong, Australia
Candice M. Monson, PhD, Department of Psychology, Ryerson University, Toronto,
Ontario, Canada
Kim T. Mueser, PhD, Center for Psychiatric Rehabilitation, Boston University,
Boston, Massachusetts
Laura K. Murray, PhD, Department of Mental Health, Johns Hopkins
Bloomberg School of Public Health, Baltimore, Maryland
Barbara Niles, PhD, National Center for PTSD, VA Boston Healthcare System,
and Department of Psychiatry, Boston University School of Medicine,
Boston, Massachusetts
Reginald D. V. Nixon, PhD, College of Education, Psychology and Social Work,
Flinders University, Adelaide, Australia
Meaghan L. O’Donnell, PhD, Phoenix Australia Centre for Posttraumatic
Mental Health and Department of Psychiatry, University of Melbourne,
Melbourne, Australia
Miranda Olff, PhD, Department of Psychiatry, Amsterdam University
Medical Centers, University of Amsterdam, Amsterdam, Netherlands;
ARQ National Psychotrauma Centre, Diemen, Netherlands
Belinda J. Pacella, MClinPsych, Phoenix Australia Centre for Posttraumatic
Mental Health and Department of Psychiatry, University of Melbourne,
Melbourne, Australia
Stephen Pilling, PhD, Division of Psychology and Language Sciences,
University College London, London, United Kingdom
x Contributors

David S. Riggs, PhD, Center for Deployment Psychology, Department of Medical

and Clinical Psychology, Uniformed Services University of the Health Sciences,
Bethesda, Maryland
Neil P. Roberts, DClinPsy, Cardiff and Vale University Health Board and Division
of Psychological Medicine and Clinical Neurosciences, School of Medicine,
Cardiff University, Cardiff, Wales, United Kingdom
Craig Rosen, PhD, National Center for PTSD, VA Palo Alto Health Care System,
Menlo Park, California
Rita Rosner, DPhil, DiplPsych, Department of Psychology, Catholic University
of Eichstätt-Ingolstadt, Eichstätt, Germany
Barbara O. Rothbaum, PhD, ABPP, Emory Healthcare Veterans Program
and Department of Psychiatry and Behavioral Sciences, Emory University School
of Medicine, Atlanta, Georgia
Mark C. Russell, PhD, School of Applied Psychology, Counseling and Family
Therapy, Antioch University, Seattle, Washington
Ulrich Schnyder, MD, Department of Consultation-Liaison Psychiatry
and Psychosomatic Medicine, University Hospital, University of Zurich,
Zurich, Switzerland
Sarah J. Schubert, PhD, private practice, Brentwood, Australia
Francine Shapiro, PhD (deceased), Mental Research Institute, Palo Alto,
California; EMDR Institute, Watsonville, California
Marit Sijbrandij, PhD, Department of Clinical, Neuro, and Developmental
Psychology and WHO Collaborating Centre for Research and Dissemination
of Psychological Interventions, Vrije University Amsterdam, Amsterdam, Netherlands
Dan J. Stein, FRCPC, PhD, SA MRC Unit on Risk & Resilience in Mental Disorders,
Department of Psychiatry and Neuroscience Institute, University of Cape Town,
Cape Town, South Africa
Shannon Wiltsey Stirman, PhD, National Center for PTSD, VA Palo Alto
Health Care System, Menlo Park, California; Department of Psychiatry
and Behavioral Sciences, Stanford University, Palo Alto, California
Yilang Tang, MD, PhD, Department of Psychiatry and Behavioral Sciences,
Emory University School of Medicine, and Atlanta VA Medical Center,
Atlanta, Georgia
Larissa Tate, MS, MPS, Department of Medical and Clinical Psychology,
Uniformed Services University of the Health Sciences, Bethesda, Maryland
Siri Thoresen, PhD, Norwegian Centre for Violence and Traumatic Stress Studies
and Department of Psychology, University of Oslo, Oslo, Norway
Maegan M. Paxton Willing, BS, Department of Medical and Clinical Psychology,
Uniformed Services University of the Health Sciences, Bethesda, Maryland
Laurence Astill Wright, MBBCH, Division of Psychological Medicine
and Clinical Neurosciences, School of Medicine, Cardiff University,
Cardiff, Wales, United Kingdom
Katarzyna Wyka, PhD, Department of Psychiatry, Weill Cornell Medicine,
New York, New York
A Note from the Editors
of the Second Edition

C ongratulations to Dave Forbes, Jon Bisson, Candice Monson, and Lucy

Berliner on overseeing this new edition. They have masterfully synthe-
sized the wide-ranging research on treating posttraumatic stress disorder
that has been conducted since the publication of the second edition in 2009.
Their editorial vision has brought a fresh perspective to the treatment guide-
lines of the International Society for Traumatic Stress Studies and offers the
field an invaluable resource. We are thrilled to see the careful work in this
arena continue, giving guidance to practitioners and researchers around the
world.

Edna B. Foa
Terence M. K eane
M atthew J. F riedman
Judith A. Cohen

xi
Preface

C linical practice guidelines, which synthesize research evidence to gen-

erate specific treatment recommendations for a particular disorder,
have been of crucial importance over the last decade in promoting a shift
toward evidence-based care. Clinical practice guidelines for posttraumatic
stress disorder (PTSD) are designed primarily to help clinicians achieve
improved mental health outcomes for people affected by trauma. The sec-
ondary goal is to assist those people and their families, as well as policy-
makers and service delivery organizations, to develop a more sophisticated
understanding of the range of available treatments and the evidence for
their efficacy.
The recent Posttraumatic Stress Disorder Prevention and Treatment Guide-
lines, on which this book is based, were published by the International Soci-
ety for Traumatic Stress Studies (ISTSS) in 2018, with earlier versions dating
back to 2000 and 2009 (as well as guidelines for the treatment of complex
PTSD in 2012). The latest guidelines build on the groundbreaking work of
the initial guidelines through adopting a standardized rigorous systematic
review of the available research literature across all the areas of focus. Simi-
lar evidence-driven guidelines for PTSD treatment have been published in
several countries, including Australia, the United Kingdom, and the United
States, with all arriving at largely similar conclusions. Although the high
degree of consensus is reassuring, this methodological approach to guide-
line development comes at a price. A heavy reliance on randomized con-
trolled trials means that other less rigorous but perhaps equally important
sources of data, as well as the nuances of clinical practice, may not be con-
sidered in generating recommendations.

xii
Preface xiii

Perhaps more important, the challenge for clinicians is often one of

how to apply the recommendations in the real world of clinical practice. It
is one thing to know what the research evidence tells us about treatments
that work. It is another thing altogether to implement those treatments in
routine clinical practice, frequently in the context of significant clinical com-
plexity, psychosocial disadvantage, and limitations in mental health delivery
systems. Clinicians may question whether the findings from sophisticated
research trials are translatable to their everyday clinical practice. They may
question their own ability to deliver those evidence-based interventions and,
perhaps, to contain any distress that might be triggered by trauma-focused
psychological interventions.
Using the latest ISTSS PTSD guidelines as the starting point, each chap-
ter of this book summarizes the research evidence base and resulting recom-
mendations reported in those guidelines. While keeping the empirical find-
ings front and center in driving the treatment recommendations, the book
stands as a natural evolution of the science by explaining not only how the
research foundations were derived but also how those findings were used to
form the basis of the recommendations.
The book goes on to bridge the gap between evidence-based guidelines
and routine practice in the real world. It is a unique contribution to the
field, with each chapter going beyond the research evidence to explore the
challenges of implementation. The authors, all specialists in their specific
treatment approaches, were asked to build on the recommendations by con-
sidering the common difficulties encountered by clinicians across a diverse
range of settings and with a broad range of trauma-affected populations.
They were encouraged to explore when and why things go wrong in treat-
ment, why some people do not respond, how we might decide to stop trying
a particular approach, and what to do at that point. The treatment chapters
are preceded by contextual chapters that outline recent developments in our
understanding of the nature, epidemiology, and assessment of mental health
responses to trauma exposure in adults, adolescents, and children, as well
as the latest evidence on prevention. Following the treatment chapters, the
book goes on to foreshadow future developments in areas such as transdiag-
nostic conceptualizations of posttraumatic mental health problems, tailor-
ing treatment to the unique needs of the individual clinical presentation,
dissemination challenges, and economic implications.
In focusing on the practical aspects of guideline implementation for
clinicians, therefore, the authors recognize the limitations of the research
and go beyond it to provide practical, clinically informed advice on how best
to use and understand the recommendations in a way that is accessible and
useful for clinicians and health service agencies.
After reading this book, clinicians will be clear about not only the spe-
cific treatment recommendations for PTSD, but also how to implement them
in varying environments and with complex clinical presentations. They will
understand where the field is heading in terms of clinical practice, research,
xiv Preface

and implementation science. By striving to adopt the advice provided by the

expert clinicians who have authored each chapter, readers will become part
of that journey as the field continues to develop. They will be up to date on
the latest thinking in the treatment of PTSD, making them a point of refer-
ence for those who practice around them and leaders in the field among
their clinical colleagues. In short, this book is essential reading for all clini-
cians working with survivors of trauma.

David Forbes, PhD

Jonathan I. Bisson, DM, FRCPsych,
Candice M. Monson, PhD
Lucy Berliner, MSW

Acknowledgments

We would like to acknowledge that this third edition of Effective Treatments

for PTSD sits on the shoulders of the work of previous editors of the first and
second editions of this book, Edna Foa, Terrence Keane, Matthew Friedman,
and Judith Cohen. Without their field leadership and insight represented in
the first two editions, this volume would not have been possible.
This book is founded on the Posttraumatic Stress Disorder Prevention
and Treatment Guidelines of the ISTSS. We thank the entire PTSD Guide-
lines Committee for their work in developing the guidelines. The commit-
tee included Jonathon I. Bisson (Chair), David Forbes (Vice Chair), Lucy
Berliner, Marylene Cloitre, Lutz Goldbeck, Tine Jensen, Catrin Lewis,
­
­Candice M. Monson, Miranda Olff, Stephen Pilling, David S. Riggs, Neil P.
Roberts, and Francine Shapiro. The editors of this volume and the PTSD
Guidelines Committee acknowledge the passing of our friends and col-
leagues in this work, Dr. Lutz Goldbeck and Dr. Francine Shapiro, both of
whom contributed enormously through their work to reduce the suffering
of people with PTSD.
Contents

I. INTRODUCTION AND BACKGROUND

1. Effective Treatments for PTSD: Guiding Current Practice 3

and Future Innovation
David Forbes, Jonathan I. Bisson, Candice M. Monson,
and Lucy Berliner

2. Trauma and PTSD: Epidemiology, Comorbidity, 13

and Clinical Presentation in Adults
Kristina J. Korte, Tammy Jiang, Karestan C. Koenen,
and Jaimie Gradus

3. Epidemiology, Clinical Presentation, 30

and Developmental Considerations in Children and Adolescents
Eva Alisic, Rowena Conroy, and Siri Thoresen

4. Diagnosis, Assessment, and Screening for PTSD 49

and Complex PTSD in Adults
Jonathan I. Bisson, Chris R. Brewin, Marylene Cloitre,
and Andreas Maercker

5. Screening, Assessment, and Diagnosis in Children and Adolescents 69

Lucy Berliner, Richard Meiser‑Stedman, and Andrea Danese

6. ISTSS PTSD Prevention and Treatment Guidelines: Methodology 90

Jonathan I. Bisson, Catrin Lewis, and Neil P. Roberts

xv
xvi Contents

7. ISTSS PTSD Prevention and Treatment Guidelines: Recommendations 109

Jonathan I. Bisson, Lucy Berliner, Marylene Cloitre,
David Forbes, Tine Jensen, Catrin Lewis, Candice M. Monson,
Miranda Olff, Stephen Pilling, David S. Riggs, Neil P. Roberts,
and Francine Shapiro

II. EARLY INTERVENTION IN ADULTS

8. Early Intervention for Trauma‑Related Psychopathology 117

Meaghan L. O’Donnell, Belinda J. Pacella, Richard A. Bryant,
Miranda Olff, and David Forbes

9. Early Pharmacological Intervention Following Exposure 137

to Traumatic Events
Jonathan I. Bisson, Laurence Astill Wright, and Marit Sijbrandij

III. EARLY INTERVENTION IN CHILDREN AND ADOLESCENTS

10. Preventative and Early Interventions 147

Justin Kenardy, Nancy Kassam‑Adams, and Grete Dyb

IV. TREATMENTS FOR ADULTS

11. Psychological Treatments: Core and Common Elements 169

of Effectiveness
Miranda Olff, Candice M. Monson, David S. Riggs, Christopher Lee,
Anke Ehlers, and David Forbes

12. Prolonged Exposure 188

David S. Riggs, Larissa Tate, Kelly Chrestman, and Edna B. Foa

13. Cognitive Processing Therapy 210

Kathleen M. Chard, Debra L. Kaysen, Tara E. Galovski,
Reginald D. V. Nixon, and Candice M. Monson

14. Eye Movement Desensitization and Reprocessing Therapy 234

Francine Shapiro, Mark C. Russell, Christopher Lee,
and Sarah J. Schubert

15. Cognitive Therapy 255

Anke Ehlers

16. Pharmacological and Other Biological Treatments 272

Jonathan I. Bisson, Matthew D. Hoskins, and Dan J. Stein
Contents xvii

17. Combined Psychotherapy and Medication Treatment 287

Mark Burton, Jessica Maples‑Keller, Mathew D. Hoskins,
Yilang Tang, Katarzyna Wyka, JoAnn Difede,
and Barbara O. Rothbaum

18. E‑Mental Health 314

Catrin Lewis and Miranda Olff

19. Complementary, Alternative, and Integrative Interventions 343

Ariel J. Lang and Barbara Niles

20. Treatment of Complex PTSD 365

Marylene Cloitre, Thanos Karatzias, and Julian D. Ford

V. TREATMENTS FOR CHILDREN AND ADOLESCENTS

21. Treatment of PTSD and Complex PTSD 385

Tine Jensen, Judith Cohen, Lisa Jaycox, and Rita Rosner

VI. APPLICATION, IMPLEMENTATION, AND FUTURE DIRECTIONS

22. Treatment Considerations for PTSD Comorbidities 417

Neil P. Roberts, Sudie E. Back, Kim T. Mueser, and Laura K. Murray

23. Building a Science of Personalized Interventions for PTSD 451

Marylene Cloitre, Zachary Cohen, and Ulrich Schnyder

24. Training and Implementation of Evidence‑Based Psychotherapies 469

for PTSD
David S. Riggs, Maegan M. Paxton Willing, Sybil Mallonee,
Craig Rosen, Shannon Wiltsey Stirman, and Shannon Dorsey

25. A Health Economics View 492

Ifigeneia Mavranezouli and Cathrine Mihalopoulos

26. The Future of Traumatic Stress Treatments: 518

Time to Grasp the Opportunity
David Forbes, Jonathan I. Bisson, Candice M. Monson,
and Lucy Berliner

Author Index 530

Subject Index 546

PA R T I

INTRODUCTION
AND BACKGROUND
C H A P TE R 1

Effective Treatments for PTSD

Guiding Current Practice and Future Innovation

David Forbes, Jonathan I. Bisson, Candice M. Monson,

and Lucy Berliner

Ebeenmpirically supported interventions to prevent and treat posttraumatic

stress disorder (PTSD) and related conditions for people of all ages have
the focus of much attention over the last two decades, resulting in a
substantial evidence base to inform clinical decisions. In this vein, there has
been a significant accumulation of evidence since the last edition of Effective
Treatments for PTSD; hence the timeliness of this third edition. This body of
evidence has the potential to provide much-­needed guidance to clinicians
and mental health service systems, as well as to people with PTSD and their
families. Concurrent with burgeoning empirical evidence on effective and
ineffective interventions, there has been a substantial increase in aware-
ness among the broader community regarding the psychological effects of
trauma exposure. The mental health of our serving personnel, veterans and
first responders, survivors of sexual and physical assault, family violence and
childhood abuse, survivors of natural and man-made disasters, and other
potentially traumatized people has become a high-­profile issue in modern
society. The topic receives widespread coverage in the media, both in cur-
rent affairs and fictional drama. This high level of community attention has
placed increasing pressure on clinicians, health service agencies, employers,
and government to provide timely, accessible, and effective care.
Although increased recognition of the effects of trauma and a more
robust knowledge base on interventions might seem optimistic, we face sig-
nificant challenges in our field. Despite the evidence base—the existence of
demonstrably effective interventions—­most people at risk of or with PTSD
still do not receive an evidence-­based intervention. This is true not only in
low- and middle-­income countries (Tol et al., 2014), but also in developed

3
4 Introduction and Background

countries with comprehensive and sophisticated mental health systems

(Rosen et al., 2017; Sripada, Pfeiffer, Rauch, Ganoczy, & Bohnert, 2018).
There are several possible explanations for this, including poor practitioner
access to clinical training and supervision in evidence-­based practices, as
well as the limited effectiveness and high cost of dissemination (Foa, Gil-
lihan, & Bryant, 2013). An important related factor, however, remains a reti-
cence by some clinicians to embrace these approaches. This may be due to
a lack of confidence in their skills to deliver the intervention and, perhaps,
to contain the potential distress that might accompany a trauma-­focused
psychological intervention. It may also be driven by misconceptions and mis-
understandings about these evidence-­based practices, and concerns about
how translatable and generalizable the rigorous protocols used in research
trials are for their own clinical practice. This book attempts to address some
of those concerns, bridging the gap between (1) research protocols that
form the basis of studies included in the evidence review that underpins
the recommendations in the recently published Posttraumatic Stress Disorder
Prevention and Treatment Guidelines (published by the International Society
for Traumatic Stress Studies [ISTSS] in 2018) represented in this book and
(2) delivery of evidence-­based practices in routine clinical practice.
The purpose of this book, therefore, is not only to summarize the research evidence
base and resulting recommendations reported in the ISTSS guidelines, but to expand
upon that evidence and operationalize the recommendations to guide clinicians in
implementing evidence-­based practices. In doing so, the authors recognize the
limitations of the research and go beyond it to provide practical, clinically
informed advice on how best to use and understand the recommendations in
a way that is accessible and useful for clinicians and health service agencies.
Consequently, this book differs from both earlier evidence summaries and
clinical treatment manuals by using the evidence base as a starting point, dis-
cussing the implementation of those treatments and practices that have been
shown to work, and going beyond the evidence to discuss the challenges and
limitations of delivering evidence-­based practices in routine clinical practice.
It is designed to be practical, useful, and applied, optimizing the value of the
ISTSS guidelines for those tasked with delivering evidence-­based practices.
It aims to address the nuances of delivering those treatments with different
populations and what to do when things do not go as planned or hoped.
The following chapters seek to improve our understanding of the
nature, epidemiology, and assessment of traumatic stress, as well as patterns
of recovery and long-term outcomes. Each of the prevention and treatment
chapters aims to summarize, and improve our understanding of, the rel-
evant guideline findings and recommendations, and in the case of chapters
on combinations of psychological and pharmacological interventions and
on complex PTSD and comorbidity, to consider important clinical presenta-
tions and approaches that were not covered by the scoping questions posed
for the guidelines. These prevention and treatment chapters explore how
the recommendations might be implemented in clinical practice, across
Effective Treatments for PTSD: Guiding Current Practice and Future Innovation 5

diverse settings and with a broad range of trauma-­affected populations. The

authors endeavor to explore when and why things go wrong in treatment,
why some people do not respond, when we might stop trying a particular
approach, and what to do at that point. Later chapters draw out the common
elements of effective evidence-­based practices, the nuances of these com-
mon elements, and their implications for clinicians. The final chapters cover
health economics, trying to address the question of “value for money,” and
consider what the future might hold in areas such as e-­health, personalized
medicine, and implementation and training.

Overview of the Contents of This Book

The introductory chapters of this book provide background information on

the nature and epidemiology of PTSD and other mental health responses to
trauma, as well as screening and assessment. Chapter 2 covers the nature of
trauma and its sequelae, clinical presentations including comorbidity, and
epidemiological issues in adults, and Chapter 3 explores clinical presenta-
tions, epidemiology, and developmental considerations in children and ado-
lescents. It is clear from these contributions that the science is evolving as
we continue to learn more about the nature and epidemiology of traumatic
stress reactions. Increasingly large datasets, combined with expanding com-
putational power, are providing opportunities to answer more complex and
sophisticated questions about symptom profiles, risk and protective factors,
and recovery trajectories. The fact that we can now devote a whole chapter in
this area to children and adolescents is testament to our growing knowledge
and understanding of developmental considerations in human responses
to trauma exposure. Similarly, Chapter 4 covers screening, assessment,
and diagnosis in adults, while Chapter 5 addresses those questions for chil-
dren and adolescents, again highlighting the importance of paying appro-
priate attention to developmental issues. Both of these chapters explore a
range of diagnostic issues, including those associated with the transition
from the fourth edition of the Diagnostic and Statistical Manual of Mental
Disorders (DSM-IV; American Psychiatric Association, 2000) to the fifth edi-
tion (DSM-5, American Psychiatric Association, 2013) and the differences
between DSM-5 and the 11th revision of the International Classification of
Diseases (ICD-11; World Health Organization, 2018). This latter comparison
is important, since the ICD-11 has taken quite a different approach to defin-
ing the essential characteristics of a PTSD diagnosis and has introduced
the new, parallel diagnosis of complex PTSD. Although it is, perhaps, too
early to comment on the potential impact of these differences in diagnostic
nomenclature for treatment recommendations, it is an important question
to be addressed in future treatment outcome studies. Chapter 6 provides
a summary of the guideline rationale, process, and methodology, before
Chapter 7 outlines the specific guideline recommendations.
6 Introduction and Background

The next three chapters focus on prevention and early intervention.

Chapters 8 and 9 discuss the guideline recommendations and implications
for clinicians of psychological and pharmacological prevention and early
interventions following trauma exposure for adults. Again, recognizing the
importance of development, Chapter 10 addresses those issues in child and
adolescent populations. These chapters highlight the current state of the
evidence for preventive interventions and make recommendations for future
directions. It is clear that prevention research in universally applied inter-
ventions is in its infancy and, at this stage, the data are not encouraging.
Early psychological intervention for those who have developed symptoms,
however, has a much more positive evidence base. These chapters provide
an opportunity to explore the different theoretical models that underpin
psychological and pharmacological early interventions, raising intriguing
questions about the mechanisms that may underpin recovery.
The next section of the book discusses the guideline recommendations
for the treatment of PTSD and related conditions in adults, along with the
implications for clinicians. Trauma-­focused psychological treatments have
the strongest level of empirical support in the treatment of PTSD. The sec-
tion begins with an overview chapter that highlights the commonalities
across the four approaches with the largest body of research support: cog-
nitive processing therapy (CPT; Resick, Monson, & Chard, 2017), cognitive
therapy for PTSD (CT-PTSD; Ehlers, Clark, Hackmann, McManus, & Fen-
nell, 2005), eye movement desensitization and reprocessing (EMDR) therapy
(Shapiro, 2018), and prolonged exposure (PE; Foa, Hembree, & Rothbaum,
2007; Foa, Rothbaum, Riggs, & Murdock, 1991). The chapter also identifies
some of the issues with which clinicians commonly struggle, as well as dis-
cussing when and why these interventions do not always seem to be effective.
These and other clinical nuances are discussed in the subsequent chapters
on each specific intervention, but this chapter aims to extract the common
elements. It also addresses the implications for clinical practice of having
four strongly recommended first-line psychological treatments.
Chapters 12, 13, 14, and 15 discuss the guideline recommendations and
implications for clinicians of PE, CPT, EMDR therapy, and CT-PTSD in more
detail. These chapters strive not only to describe the intervention and the
available empirical support, but also to go beyond those factors to explore
the challenges of implementation in routine, real-world clinical practice.
The authors recognize that, although these remain the first-line treatments
of choice for PTSD, there are limitations and that not everyone will achieve
clinically significant benefits. The authors explore why that might be and,
more importantly, what we as clinicians might do in those circumstances.
These chapters are prefaced by Chapter 11, which outlines the psychologi-
cal treatment recommendations overall and identifies the common ingredi-
ents among these four most strongly recommended treatments. The chapter
examines the potentially shared putative mechanisms underlying these four
recommended treatments and the implications of these mechanisms for
other recommended psychological interventions.
Effective Treatments for PTSD: Guiding Current Practice and Future Innovation 7

Although trauma-­focused psychological treatments have the strongest

empirical support and remain the first-line treatment, pharmacological inter-
ventions have an important role to play in the comprehensive management
of PTSD. Chapter 16 reviews the evidence for pharmacological approaches
for adults and discusses the guideline recommendations. The authors recog-
nize that clinicians do not always stick rigidly to the evidence base, with pre-
scribing decisions often being made on the basis of the specific clinical pre-
sentation, response to initial pharmacotherapy, and personal preference. To
assist clinicians in this difficult process, the authors provide an algorithm—­a
decision-­making tree based on the available evidence, with advice on which
medications to try in which order. In routine clinical practice, psychological
therapy and pharmacotherapy are often provided concurrently, especially in
more complex and chronic cases. Chapter 17 reviews the evidence on com-
bining pharmacological and psychological treatment, discussing the guide-
line recommendations and their implications for treatment.
With the ubiquitous availability of technology and the Internet, includ-
ing handheld devices, the field of “e-­health” has received increasing atten-
tion in recent years. In the trauma field, several online intervention options
and mobile “apps” have been proposed as both stand-alone and adjunct
treatments. Chapter 18 reviews the emerging evidence on these approaches.
Although the authors note the need for more research, it is clear that techno-
logical approaches provide intriguing possibilities for improving treatment
options, especially for people in rural and remote locations, as well as in
boosting the efficacy of more traditional approaches. The authors explore
the issues and challenges faced by clinicians who wish to integrate techno-
logical approaches into their practice.
Increasing awareness of the mental health effects of trauma has resulted
in much greater attention being paid to the quality and accessibility of treat-
ment. Alongside a focus on mainstream approaches, a wide range of alterna-
tive interventions to treat PTSD and related conditions has been proposed.
Some of these have a track record in the treatment of other conditions,
strong theoretical underpinnings, and an emerging evidence base. Others
are less well developed, but nevertheless have strong proponents. The chal-
lenge for the field is to be open to new ideas and innovations, while still
adhering to scientific principles and a commitment to evidence-­based treat-
ment (EBT). Chapter 19 explores some of the alternative approaches that
show early promise as treatments in their own right, or as adjuncts to first-
line treatments with the aim of improving quality of life, and discusses the
guideline recommendations in this area. Again, the challenge for clinicians
is whether and how to incorporate some of these approaches into their treat-
ment planning and practice.
Although the concept of complex PTSD has been discussed in the litera-
ture for many years, it was not until the advent of ICD-11 that the disorder
was formally recognized in the diagnostic nomenclature. Chapter 20 dis-
cusses the diagnostic criteria and treatment recommendations, before con-
sidering the challenges faced by clinicians working in this area.
8 Introduction and Background

Chapter 21 discusses the evidence base for psychological and pharma-

cological treatments for PTSD in adolescents and children. Notably, there
has been significant development in the evidence base since the last guide-
lines were published, and three psychosocial treatments receive strong rec-
ommendations. Psychopharmacological treatments have so far not been
shown to be effective for children. Although not yet at the same level as
interventions for adults, we can be more confident about the efficacy of
some approaches now than we were previously.
The final group of chapters are more exploratory in nature. Chapter
22 explores the complex issue of comorbidity and transdiagnostics. A high
degree of overlap in symptoms and clinical presentation exists across sev-
eral of the high-­prevalence conditions, and PTSD is no exception. The fact
that the disorder is characterized by features of depression, anxiety, and
(in many cases) dissociation raises the question of whether current diag-
nostic systems that conceptualize disorders as discrete categories represent
the most useful model. The authors grapple with this issue and discuss the
implications for clinicians. Chapter 23 takes this discussion to the next level,
exploring the implications of different clinical presentations of PTSD on
our conceptualizations of treatment models. The authors argue for a more
personalized approach to intervention in the future, with the treatment plan
better matched to the specific needs of the individual. They go on to discuss
the challenges of progressing this individualized approach, while still retain-
ing a commitment to the scientific method and EBT.
The best PTSD treatments in the world are of little use unless they are
adopted by mental health practitioners working in routine clinical settings.
Chapter 24 addresses the challenges of dissemination and implementation,
exploring what needs to be done in order to improve the uptake of EBTs by
clinicians. In a related vein, Chapter 25 reviews the economic implications of
the guidelines. Drawing on international data, particularly from the United
Kingdom and Australia, the authors highlight the potential economic ben-
efits to be gained by widespread adoption of the guideline recommenda-
tions. Finally, Chapter 26 foreshadows future opportunities to advance more
sophisticated approaches to understanding the nature and course of human
responses to trauma, the mechanisms underlying those different trajecto-
ries, and how best to improve our treatments and implement best-­practice
interventions.

The ISTSS Posttraumatic Stress Disorder Prevention

and Treatment Guidelines Process

Several clinical practice guidelines now exist to guide the treatment of PTSD
and related conditions (American Psychological Association, 2017; Depart-
ment of Veterans Affairs & Department of Defense Clinical Practice Work-
ing Group, 2017; National Institute for Health and Care Excellence, 2005;
Effective Treatments for PTSD: Guiding Current Practice and Future Innovation 9

Phoenix Australia—­Centre for Posttraumatic Mental Health, 2013). Most of

these are based on a systematic literature review process that uses clearly
defined and internationally agreed-­upon methods to collect and collate the
research data, critically appraise research studies, and synthesize the find-
ings to generate recommendations graded by the strength of the evidence.
The recently published (2018) ISTSS guidelines represented in this book
also adopted this approach (Bisson et al., 2019). As such, they embrace cur-
rently accepted gold standards for guideline development and represent
a substantial change in methodology compared to the two earlier guide-
lines produced by ISTSS. The latest version provides an important addition
to the growing body of evidence-­based clinical practice guidelines in the
trauma field and provides the platform upon which the chapters in this book
build. The authors, who are not only leaders in their particular treatment
approaches but also experienced clinicians, recognize that treatment guide-
lines alone do not change practice. They understand how hard it can be
for clinicians to interpret and implement the guideline recommendations in
their routine clinical work, and they are acutely aware of the clinical com-
plexity that often confronts practitioners working with the mental health
effects of trauma. The fact is that, despite substantial progress in the field of
traumatic stress, many questions remain unanswered and many challenges
confront those providing treatment.
As highlighted previously, Chapter 6 describes the rationale, process,
and methodology used to develop the ISTSS guidelines (ISTSS, 2018), as
well as summarizing the guideline recommendations themselves. Briefly, the
process followed a rigorous systematic review approach, beginning with the
development of explicit scoping questions. In developing the ISTSS guide-
lines, a systematic review identified 361 randomized controlled trials (RCTs)
according to the a priori agreed inclusion criteria. There were 208 meta-­
analyses conducted, resulting in 125 recommendations (24 for children and
adolescents and 101 for adults). An agreed-­upon definition of clinical impor-
tance and strength of recommendation resulted in 8, Strong; 8, Standard; 5,
Intervention with Low Effect; 26, Intervention with Emerging Evidence; and 78,
Insufficient Evidence to Recommend recommendations. Narrative reviews were
undertaken and two position papers (one for children and adolescents, and
one for adults) were prepared to address current issues in complex PTSD
and to make recommendations for further research. The draft recommen-
dations were posted on the ISTSS website during August and September
2018 for a period of consultation by ISTSS members. Feedback from ISTSS
members was reviewed and incorporated into the final recommendations,
which were approved by the ISTSS Board in October 2018.
The adoption of a systematic review approach to developing clinical
practice guidelines helps to ensure transparency and replicability by estab-
lishing key elements of the process prior to commencement: scoping ques-
tions, inclusion/exclusion criteria for papers, definition of clinical impor-
tance, and a recommendation generation algorithm. This rigorous approach
10 Introduction and Background

helps to reduce the risk of inconsistency and conscious or implicit bias of

committee members influencing the recommendations. It is consistent with
an internationally accepted commitment to evidence-­based practice and is a
fundamental starting point in establishing first-line treatments.
Notwithstanding those benefits, adoption of a systematic review meth-
odology in guideline development also has some limitations. For example,
systematic reviews often limit the number of questions that can be addressed,
either because they are not asked or because no solid data exist. This may
result in some potentially important issues, especially around implemen-
tation in clinical practice—­for example, in areas such as comorbidity—­not
being adequately explored. Despite rigorous selection criteria for inclusion,
it is possible that methodological differences across studies may influence
the interpretation of results and, therefore, the recommendations. System-
atic reviews need to decide, a priori, on the primary outcomes of interest—­in
this case, PTSD symptom reduction. Clearly, in routine clinical practice,
other outcomes might be equally (or more) important goals for interven-
tion. Finally, and perhaps most importantly, a focus on RCTs in a system-
atic review may result in other important evidence being omitted (e.g., large
observational cohort studies, nonrandomized controlled studies such as
larger uncontrolled program evaluation studies, longer-­term follow-­ups, and
“evidence from practice”). Despite the lack of methodological rigor, those
pieces of evidence have the potential to contribute to a more accurate assess-
ment of the effectiveness of a particular intervention in routine clinical prac-
tice. By going beyond the systematic review, this book allows the proponents
of each approach to draw on that body of data and to recognize the impor-
tance of other, real-world factors that may be important to consider in the
adoption and utilization of the guideline recommendations. This approach
echoes the sentiments of the founders of evidence-­based practice when they
noted, “Good doctors use both individual clinical expertise and the best
available external evidence, and neither alone is enough” (Sackett, Rosen-
berg, Muir Gray, Haynes, & Richardson, 1996, p. 72).

Summary

This book is designed to be a practical guide for those working with survi-
vors of trauma. The starting point is the systematic review of the research
evidence, and the resultant recommendations, contained in the ISTSS (2018)
Posttraumatic Stress Disorder Prevention and Treatment Guidelines. That docu-
ment illustrates just how far the field has come since the diagnosis of PTSD
was first formally recognized in the diagnostic nomenclature in DSM-III
(American Psychiatric Association, 1980) 40 years ago. Equally, we need to
recognize the limitations of the research data for practicing clinicians and
interpret the guideline recommendations to address the complexity that we
routinely see in clinical practice. This book builds on the guidelines, going
Effective Treatments for PTSD: Guiding Current Practice and Future Innovation 11

beyond the recommendations to make them useful for clinicians, service

providers, and health and mental health service systems.

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American Psychological Association. (2017). Clinical practice guideline for the treat-
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Bisson, J. I., Berliner, L., Cloitre, M., Forbes, D., Jensen, T. K., Lewis, C., et al. (2019).
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Department of Veterans Affairs & Department of Defense Clinical Practice Work-
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traumatic stress disorder and acute stress disorder. Washington, DC: VA Office of
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Ehlers, A., Clark, D. M., Hackmann, A., McManus, F., & Fennell, M. (2005). Cogni-
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treating-­trauma/new-istss-­prevention-­and-­treatment-­g uidelines.
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der: The management of PTSD in adults and children in primary and secondary care.
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12 Introduction and Background

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order 18 months after training. Journal of Traumatic Stress, 30, 63–70.
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C H A P TE R 2

Trauma and PTSD

Epidemiology, Comorbidity,
and Clinical Presentation in Adults

Kristina J. Korte, Tammy Jiang, Karestan C. Koenen,

and Jaimie Gradus

Tandraumatic events, such as natural disasters, automobile and other acci-

dents, sexual assault, and child abuse are common throughout the world
can take a tremendous psychological toll on individuals and communi-
ties. In this chapter, we present information about the global public health
burden posed by trauma exposure. To accomplish this goal, we review the
prevalence and distribution of traumatic events and trauma-­related disor-
ders from epidemiological studies, with a focus on posttraumatic stress dis-
order (PTSD). We also review the prevalence of disorders that commonly
co-occur with PTSD and provide an overview of the clinical presentation of
PTSD.
Epidemiology is the science of public health and focuses on the distribu-
tion and causes of disease in human populations, as well as developing and
testing ways to prevent and control disease. Epidemiological studies provide
empirical evidence on the high prevalence of trauma and the devastating
effects of trauma-­related disorders, and show that trauma is not equally dis-
tributed across populations. When presenting the results throughout this
chapter, we note methodological considerations that make cross-study com-
parisons difficult. Although the focus in epidemiology is on populations
and not individuals, to illustrate epidemiological findings we provide pro-
totypical cases of trauma exposure and common trajectories observed (e.g.,
normal recovery and diagnosis of PTSD).

13
14 Introduction and Background

The Epidemiology of Trauma Exposure

Trauma exposure is common globally. A traumatic event is defined as

exposure to actual or threatened death, serious injury, or sexual violence
according to the fifth edition of the Diagnostic and Statistical Manual of Men-
tal Disorders (DSM-5; American Psychiatric Association, 2013). Individuals
can be exposed to a traumatic event by directly experiencing the traumatic
event, witnessing in person the event as it occurred to others, learning that
the traumatic event occurred to a close family member or close friend, or
experiencing repeated or extreme exposure to aversive details of traumatic
events (American Psychiatric Association, 2013). Approximately 70% of
respondents in the World Health Organization’s World Mental Health Sur-
veys (WMHS) have experienced one or more traumas (Kessler et al., 2017).
Globally, each person experiences an average of 3.2 lifetime traumas (Kes-
sler et al., 2017). The most common traumatic events worldwide include
witnessing death or serious injury, experiencing the unexpected death of a
loved one, being mugged/assaulted, being in a life-­threatening automobile
accident, and experiencing a life-­t hreatening illness or injury (Benjet et al.,
2016). Combined, these five traumatic events account for over half of all
instances of trauma exposure globally (Benjet et al., 2016). In the following
material, we discuss factors that affect the prevalence of trauma exposure,
including changes in the definition of a traumatic event, and heterogeneity
in the people and places assessed.

Changes in the Definition of a Traumatic Event

The newest iteration of the DSM, the main diagnostic classification system
used in the United States, resulted in three major changes in the defini-
tion of trauma from DSM-IV to DSM-5 that might impact the incidence
and prevalence of trauma and PTSD. DSM-IV included a requirement of
particular emotional responses to a traumatic event (Criterion A2). Thus,
individuals who did not endorse fear, helplessness, or horror during a trau-
matic event could not receive a diagnosis of PTSD, even if they met the rest
of the diagnostic criteria for PTSD (Pai, Suris, & North, 2017). In DSM-5,
the requirement for emotional responses to a traumatic event is removed. A
second change to the definition of trauma from DSM-IV to DSM-5 was that
DSM-5 removed the term “threat to physical integrity” from the definition
of trauma. Nonacute, noncatastrophic, life-­t hreatening illness (e.g., terminal
cancer) no longer qualifies as trauma, regardless of how stressful or severe
it is (Pai et al., 2017). This change has been found to reduce the number
of PTSD cases (Kilpatrick et al., 2013). A third change to the definition
of trauma in the newest iteration of DSM was that DSM-IV-TR allowed for
indirect exposure to trauma (without being present) at the time of the trau-
matic event, whereas DSM-5 added a new requirement for the witnessing
Epidemiology/Comorbidity/Clinical Presentation: Adults 15

of trauma to others to be “in person.” Repeated or extreme exposure to

aversive details of the traumatic event was added to DSM-5, but does not
apply to exposure through electronic media, television, movies, or pictures,
unless this exposure is work-­ related (American Psychiatric Association,
2013). Police officers, firefighters, ambulance personnel, and health care
personnel often experience indirect traumatic events, such as witnessing the
suffering of others as part of their work (Skogstad et al., 2013). The nature
of the trauma witnessing may also be an important factor, such as dealing
with child victims of abuse (North et al., 2002; Skogstad et al., 2013). More
details about the diagnostic criteria for PTSD and the criteria as outlined in
ICD-11 (which is used primarily outside of the United States) can be found in
Bisson, Brewin, Cloitre, and Maercker (Chapter 4, this volume).

The Heterogeneity in the Prevalence

of Trauma Exposure across Countries

The prevalence of trauma exposure varies across countries. According to

the World Health Organization’s WMHS, which are general population
studies carried out throughout the world from 2001 until 2012 that used the
DSM-IV definition of trauma, the prevalence of exposure to any traumatic
event ranged from a high of 83% in the United States and Colombia to a
low of 29% in Bulgaria (Benjet et al., 2016). Varying prevalence estimates
of trauma exposure across countries may be due to true differences, differ-
ences in willingness to disclose traumatic events, and measurement error
(Benjet et al., 2016). For example, sexual violence is highly stigmatized in
many settings and the fear of being blamed and a perceived lack of support
lead to underreporting of sexual violence (Abrahams et al., 2014).

Risk Factors for Trauma Exposure

Predictors of Trauma Exposure
Trauma exposure varies by individual and contextual factors that include
sex, age, race/ethnicity, sexual orientation, educational attainment, marital
status, genetics, risk-­taking behavior, and neighborhood of residence (Benjet
et al., 2016; Kessler et al., 2017; Roberts, Austin, Corliss, Vandermorris, &
Koenen, 2010). Women are more likely than men to be exposed to intimate
partner violence, whereas men are more likely than women to experience
physical violence and unintentional injuries (Benjet et al., 2016). Traumas
related to interpersonal violence have the earliest median age of occur-
rence (age 17), followed by intimate partner violence (age 18), war-­related
traumas (age 20), and unintentional injuries, unexpected deaths of loved
ones, and other traumas with later median ages of occurrence (ages 24–31).
The pattern of trauma exposure across age may reflect differences in life
16 Introduction and Background

circumstances and lifestyles (Kessler et al., 2017). There are also racial/eth-
nic differences in types of traumas experienced. For example, blacks and
Hispanics have a higher risk of child maltreatment and witnessing domes-
tic violence than whites. Asians, black men, and Hispanic women are more
likely to be exposed to war-­related traumatic events than whites (Roberts et
al., 2010). Assessments of sexual orientation disparities in exposure to vio-
lence and other traumatic events in a representative U.S. sample found that
lesbians, gay men, bisexuals, and heterosexuals who reported any same-sex
sexual partners during their lifetime had an increased risk of childhood
maltreatment, interpersonal violence, trauma to a close friend or relative,
and unexposed death of someone close, compared to heterosexuals with-
out same-sex attractions or partners (Roberts et al., 2010). Low educational
attainment is associated with elevated risk of some traumas (e.g., violence,
unintentional injuries, and natural disasters) but not all traumas (e.g., unex-
pected death of a loved one). Higher levels of educational attainment are
associated with a lower risk of being raped, being beaten up by a spouse or
romantic partner, or stalked, but is associated with increased risk of non-
penetrative sexual assault and traumatic event to a loved one (Kessler et al.,
2017). Married individuals have a reduced risk of experiencing most trauma
types compared to the never married, perhaps due to married individuals
spending less time outside the home at later hours, unaccompanied, and in
potentially vulnerable situations (Benjet et al., 2016). Genetic factors may
affect the risk of exposure to trauma, possibly through individual differ-
ences in personality that influence environmental choices (Stein, Jang, Tay-
lor, Vernon, & Livesley, 2002). Individual traits such as impulsivity and risk
taking may increase the risk of traumatic events such as injuries (Romer,
2010). Neighborhoods that are highly disorganized (i.e., neighborhoods with
high levels of poverty, family disruption, and residential mobility) are asso-
ciated with higher levels of exposure to violence and crime, which could
potentially be traumatic (Butcher, Galanek, Kretschmar, & Flannery, 2015).

Trauma Exposure Increases Risk of Subsequent Exposure

to Trauma
Having experienced trauma increases one’s risk of experiencing additional
traumas later in life (Benjet et al., 2016; Gradus, Antonsen, et al., 2015). Over
30% of respondents to the WMHS were exposed to four or more traumatic
events (Kessler et al., 2017). Exposure to childhood abuse is strongly asso-
ciated with additional trauma exposure later in adulthood, and exposure
to interpersonal violence is strongly associated with subsequent exposure
to interpersonal violence (Benjet et al., 2016; Coid et al., 2001). Potential
mechanisms underlying this association include perpetrators targeting indi-
viduals who have low self-­esteem, are socially isolated, feel powerless, or
have other psychological sequelae of previous victimization (Benjet et al.,
2016; Coid et al., 2001; Grauerholz, 2000). Furthermore, impulsivity and risk
Epidemiology/Comorbidity/Clinical Presentation: Adults 17

taking, which may be both predictors and outcomes of trauma exposure,

may also increase the risk of experiencing multiple traumatic events (e.g.,
injuries; Benjet et al., 2016).

Trauma Exposure and Natural Recovery

It is common to experience some psychological distress and PTSD-­related
symptoms immediately after enduring a traumatic event, such as fear, somatic
symptoms, and sleeping disturbances (Sayed, Iacoviello, & Charney, 2015).
However, many individuals experiencing a traumatic event will not develop
PTSD (Atwoli, Stein, Williams, McLaughlin, & Koenen, 2015). Of those expe-
riencing some PTSD-­related symptoms most, if not all of the symptoms will
dissipate within a month for a majority of individuals (Littleton, Axsom, &
Grills-­Taquechel, 2011), reflecting a course of natural recovery.

CASE EXAMPLE: Anne Marie—­Normal Recovery

Anne Marie is a 27-year-old Hispanic female. She works as a pediatric nurse
at a local hospital. One night, after finishing a long shift at midnight, Anne
Marie said goodbye to her colleagues and left the pediatric ward, heading
toward her car in the outside parking lot. She was parked in her usual park-
ing spot in the back corner. As Anne Marie headed out to her car, she noted
it was quite dark because the light post above her car appeared to have gone
out. Once she got to her car, she unlocked the door and started to climb
inside when she felt something pressed to her side and a low voice say, “Give
me your car keys and I will not hurt you.” Anne Marie quickly realized that
someone was holding a gun to her side and that she was being robbed. As
she moved to give the perpetrator her keys, he grabbed her arm, took her car
keys, threw her to the ground, and kicked her in her stomach. The man sped
away in her car, and after a few minutes Anne Marie was able to stumble to
the hospital emergency room for an evaluation and to receive treatment for
her injuries. Although she did not have any serious injuries, she experienced
psychological distress from her assault and felt fearful and more cautious
than usual as she went about her daily activities. In the following days, Anne
Marie dreaded driving to work so much that she had her boyfriend drive her
to and from work for the first week after the assault. The following week,
Anne Marie knew she could not depend on her boyfriend to continue to
drive her to work, so she began driving to work again, making sure that she
was parking in spaces closest to the entrance of the hospital. When leaving
work, she would also scan the parking lot for “suspicious”-looking men. After
a few weeks, however, Anne Marie began to feel more secure as she realized
that the likelihood of being assaulted in the parking lot again was low, her
experience was the only assault reported in the last decade, and her symp-
toms began to dissipate. By the end of the month, she no longer scanned
parking lots for “suspicious” males and began parking in her usual parking
18 Introduction and Background

space at the hospital again. Anne Marie’s reaction to her assault represents a
typical reaction to experiencing a traumatic event.

Epidemiology of PTSD and Other Psychological

Consequences of Trauma Exposure

As reviewed in the prior section, exposure to traumatic events is a com-

mon occurrence throughout the world. Although most people exposed to
traumatic events will not go on to experience clinical levels of psychological
distress, there is a significant portion of individuals who develop problems.
Exposure to traumatic events can have a significant impact on psychological
functioning and, in some cases, lead to mental health disorders. Although
there is a variety of psychological consequences that can emerge after expo-
sure to a traumatic event, such as acute stress disorder, adjustment disor-
ders, and complicated grief—to name a few—PTSD is one of the most com-
mon and tends to receive the most attention as a psychological consequence
of trauma exposure.
In general, PTSD is among the most prevalent mental health disorders
in the United States, with approximately 2.5% of the general population
meeting diagnostic criteria in any given year (Karam et al., 2014). This prev-
alence is significantly higher in the U.S. veteran population, with up to 15%
of veterans meeting diagnostic criteria for PTSD (Seal et al., 2009). Approx-
imately 8% of the population in the United States (Kessler, Petukhova,
Sampson, Zaslavsky, & Wittchen, 2012), 4.4% in the United Kingdom (Fear,
Bridges, Hatch, Hawkins, & Wessely, 2014), and 4.4% in Australia (McEvoy,
Grove, & Slade, 2011) will be diagnosed with PTSD in their lifetime, which
is second only to the prevalence of depression in these countries (Kessler et
al., 2012; McEvoy et al., 2011). More generally, a pattern of PTSD prevalence
across countries reveals that high-­income countries report higher prevalence
estimates of lifetime PTSD (6.9%) than those in middle- (3.9%) and low-­
income countries (3%; Koenen et al., 2017). Past 30-day prevalence follows
a similar pattern, with high-­income countries reporting the highest preva-
lence (1.9%) and middle- (0.7%) and low-­income (0.6%) countries reporting
lower prevalence of PTSD. Although these differing prevalence estimates
may reflect true differences in the prevalence of PTSD across cultures, they
may also be partially due to low reporting related to cultural factors such
as mental health stigma, less understanding of mental health issues, and
measurement error (Wang et al., 2007). Age of onset of PTSD tends to be
younger in high-­income countries than in low- and middle-­income countries.
The age of onset in high-­income countries is generally before the age of
30, whereas the age of onset in low- and middle-­income countries is gen-
erally before the age of 43 (Koenen et al., 2017). Moreover, despite ques-
tions of whether the changes in the PTSD diagnostic criteria from DSM-
IV to DSM-5 would impact prevalence estimates, recent investigations have
Epidemiology/Comorbidity/Clinical Presentation: Adults 19

shown comparable prevalence estimates of PTSD when using DSM-IV versus

DSM-5 criteria (Hoge, Riviere, Wilk, Herrell, & Weathers, 2014; Kilpatrick
et al., 2013; Stein et al., 2014). When expanding beyond the DSM classifica-
tion system, there tends to be an overlap between those meeting criteria
for PTSD using DSM-5 and ICD-11; however, a substantial portion of those
meeting criteria using one diagnostic system did not meet criteria using the
other system (O’Donnell et al., 2014).

Correlates and Risk Factors of PTSD

Research demonstrates that socioeconomic and psychological factors pre-

dict PTSD diagnosis. Sociodemographic factors—­including lower levels of
educational attainment and income, prior exposure to trauma, preexisting
psychopathology, white ethnicity (although these findings have been incon-
sistent), and female sex—are associated with a higher risk of PTSD. For exam-
ple, women have twice the risk of PTSD as men (Kessler et al., 2005; Perrin et
al., 2014). Also, personality variables such as being high in neuroticism and
having poor coping responses are also associated with greater risk of PTSD
(Perrin et al., 2014).
In addition to individual characteristics associated with PTSD, type of
trauma itself has also been shown to be associated with this disorder. The
psychological consequences of trauma exposure tend to be more severe and
disabling subsequent to some types of trauma such as sexual assault and
other forms of interpersonal violence (Breslau, 2009; Pietrzak, Goldstein,
Southwick, & Grant, 2011). Events viewed to be “intentional” (e.g., assault) are
associated with greater persistence of PTSD symptoms than those exposed
to “nonintentional” traumatic events (e.g., natural disorders; Santiago et
al., 2013). Number of traumatic events experienced is also associated with
elevated risk. Experiencing four or more events significantly increases one’s
risk for PTSD compared to experiencing three or fewer traumatic events
(Karam et al., 2014). Posttrauma variables also increase risk for PTSD. In
particular, low perceived social support and subsequent life stressors (e.g.,
ongoing financial problems) are associated with greater severity of PTSD
symptoms (Ozer, Best, Lipsey, & Weiss, 2003) and PTSD diagnosis (Brewin,
Andrews, & Valentine, 2000; Bryant et al., 2018; Ozer et al., 2003).

Course and Impact on Functioning

PTSD is a disabling mental health disorder (Smith, Schnurr, & Rosenheck,

2005) associated with substantial societal costs and burden (Breslau, Lucia,
& Davis, 2004; Kessler, 2000). Greater impairment among persons with
PTSD appears to be associated with the number of traumatic events experi-
enced. Findings from 20 population surveys (11 from high-­income countries
20 Introduction and Background

and nine from low- and middle-­income countries) from the WMHS found
that, of individuals reporting PTSD symptoms, approximately 20% reported
that their symptoms were associated with multiple traumatic events (Karam
et al., 2014). Moreover, the 12-month PTSD cases that reported experienc-
ing four or more traumatic events also had greater functional impairment,
earlier age of onset, more enduring PTSD symptoms, and more comorbid-
ity with other mental disorders, such as mood and anxiety disorders. Thus,
it appears that individuals with PTSD who have experienced four or more
traumatic events may reach a “risk threshold” that sets these patients on a
more severe and impairing PTSD course (Karam et al., 2014), and possibly
a more chronic trajectory than those experiencing fewer traumatic events.

Treatment Seeking

Without treatment, PTSD tends to be chronic, although it is typical for indi-

viduals to experience a fluctuation in symptoms, including the remitting
and reemergence of symptoms over time (Solomon & Mikulincer, 2006).
Early research on the lifetime course of PTSD found that approximately
two-­t hirds of those with PTSD will remit from the disorder over time; how-
ever, the remaining one-third will not remit from PTSD without treatment
(Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995). Research data from
WMHS indicate that 20–440% of PTSD cases will remit within 1 year. Of
those cases, most will remit within the first 6 months (Kessler et al., 2017).
Despite the generally chronic course and disability associated with PTSD,
rates of treatment seeking remain low. Respondents to the WMHS report
that less than 50% of those individuals with PTSD received some form of
treatment (Koenen et al., 2017). Treatment is most common among persons
living in high-­income countries where the probability of treatment seeking
is twice that of lower economic regions (Koenen et al., 2017). Even among
patients who receive treatment, there may be a significant delay in treatment
initiation. Data collected by the National Epidemiologic Survey on Alcohol
and Related Conditions–­III (NESARC-­III) from 36,309 adults showed that,
of those with PTSD, approximately 59% sought treatment, with an aver-
age delay of 4.5 years before receiving treatment (Goldstein et al., 2016).
NESARC-­III respondents reported most commonly talking to a therapist or
mental health counselor (54.6%), receiving prescribed psychiatric medica-
tions (33.7%), or being involved in support groups (17.2%; Goldstein et al.,
2016).
The gap between diagnosis and seeking treatment is largest in low-­
income counties, where less than 25% of individuals with PTSD receive treat-
ment (Koenen et al., 2017; Wang et al., 2007). The decreased availability
of treatment resources in low-­income countries has led to a global effort
to improve screening for mental health problems, including trauma expo-
sure and PTSD, and to provide treatments using novel approaches, such
Epidemiology/Comorbidity/Clinical Presentation: Adults 21

as telehealth approaches (Nasland et al., 2017) and the use of “task shar-
ing” (i.e., providing treatments in nontraditional settings administered by
lay providers, such as nurses in primary care centers; Eaton et al., 2011;
Patel, Chowdhary, Rahman, & Verdeli, 2011). Although this line of research
is nascent, preliminary findings show that the use of task sharing and other
novel treatment approaches is effective (Hanlon et al., 2014; Patel et al.,
2011) and may help in the scaling up of effective treatments in low-­resource
settings worldwide (Eaton et al., 2011).

Comorbidity of PTSD
Comorbidity of PTSD and Other Mental Health Disorders
Approximately 78% of individuals diagnosed with PTSD also meet criteria
for at least one additional mental health disorder in their lifetime (Koenen
et al., 2017). Co-­occurrence of PTSD with mood disorders, and in particular
unipolar depression, is especially high, with over half of those with PTSD
also meeting criteria for depression (Kessler et al., 2005). The co-­occurrence
of PTSD and anxiety disorders is also common (Gradus, Antonsen, et al.,
2015; Kaufman & Charney, 2000; Kessler et al., 2005). Epidemiological find-
ings from the NESARC-­III data showed that individuals with PTSD had
greater odds (odds ratio = 4.3, 95% confidence interval = 3.8, 4.8) of being
diagnosed with an anxiety disorder than those without PTSD (Pietrzak et al.,
2011). Mood and anxiety disorders tend to be preexisting conditions before
the onset of PTSD and in some cases may represent a risk factor for PTSD
(Bromet, Sonnega, & Kessler, 1998; Perkonigg, Kessler, Storz, & Wittchen,
2000), although the alternative has also been found, in which mood and
anxiety disorders tend to have an onset that follows a PTSD diagnosis (Gra-
dus, Antonsen, et al., 2015). It has been argued that the high prevalence of
comorbidity among mood and anxiety disorders and PTSD may be attrib-
uted to underlying vulnerability factors shared across the disorders (i.e.,
shared genetic vulnerability: Duncan et al., 2018; neuroticism: Brown &
Barlow, 2009), or shared diagnostic symptom clusters across the disorders
(e.g., dysphoric symptoms in both depression and PTSD; Simms, Watson, &
Doebbeling, 2002), or may actually represent a distinct phenotype (Flory &
Yehuda, 2015).
Comorbid substance use disorders (SUDs) are highly prevalent among
those with PTSD, with approximately 40% of individuals with PTSD also
meeting criteria for a co-­occurring SUD (Blanco et al., 2013; Pietrzak et al.,
2011). Interestingly, SUDs tend to emerge after a PTSD diagnosis (Kessler
et al., 2005), and likely reflect a tendency for those with PTSD to use sub-
stances as a self-­medicating strategy to mitigate the distressing symptoms
of PTSD (Gradus, Antonsen, et al., 2015; Stewart & Conrod, 2003). This
suggests that PTSD may serve as a risk factor for the later development of
SUDs.
22 Introduction and Background

PTSD is also associated with increased risk for suicide. Epidemiologi-

cal studies report that individuals with PTSD have approximately a sixfold
increase in risk for suicidal ideation and suicide attempts (Kessler, Borges,
& Walters, 1999; Sareen, Cox, & Asmundson, 2005). For example, in a Dan-
ish cohort study, patients with PTSD had 13 times the rate of death by sui-
cide than patients without PTSD (Gradus, Antonsen, et al., 2015). The high
prevalence of PTSD and co-­occurring mental disorders, such as depression
and SUDs, paired with increased rates of suicidality, problematic anger
(McHugh, Forbes, Bates, Hopwood, & Creamer, 2012; Olatunji, Ciesielskil,
& Tolin, 2010), guilt (Lee, Scragg, & Turner, 2001), and dissociation (Bry-
ant, 2007; Stein et al., 2013) make this clinical profile a particularly impor-
tant target for efforts aimed at the prevention and treatment of these often
comorbid clinical problems.

Comorbidity of PTSD and Physical Health Problems

Although PTSD has long been implicated in the development of various
physical health disorders, such as gastrointestinal disorders (Gradus et al.,
2017; Kessler, 2000; Schnurr & Jankowski, 1999) and other somatic disorders
(Pacella, Hruska, & Delahanty, 2013), findings have been relatively mixed
for these disorders (Pacella et al., 2013). There is stronger evidence for an
association between PTSD and cardiovascular disease (CVD). Support for
the link between PTSD and CVD has been found in veteran samples (Beris-
tianos, Yaffe, Cohen, & Byers, 2016; Vaccarino et al., 2013) and in the gen-
eral population (Gradus et al., 2015). Individuals with PTSD have greater
odds (odds ratio = 3.4, 95% confidence interval = 1.9, 6.0) of heart failure
than those without PTSD (Spitzer et al., 2009). It is unclear whether having
PTSD increases the risk of CVD or if the two disorders share an underlying
vulnerability, but there is some evidence of a dose–­response relationship, in
which those with a greater number of PTSD symptoms have higher levels of
hypertension (Sumner et al., 2016). Similarly, there is a strong association
between PTSD and pain disorders (Otis, Keane, & Kerns, 2003), with 30% of
the general population suffering from PTSD and a co-­occurring pain disor-
der (Asmundson, Coons, Taylor, & Katz, 2002). Possible explanations for the
comorbidity of PTSD and chronic pain include a shared underlying vulner-
ability, such as elevated levels of anxiety sensitivity (Asmundson et al., 2002),
and mutual maintenance models, whereby the presence of PTSD symptoms
increases pain-­related distress, and vice versa (Asmundson & Katz, 2009;
Sharp & Harvey, 2001).

CASE EXAMPLE: Michael—­PTSD and Co-­Occurring Alcohol

Use Disorder
Michael is a 24-year-old combat veteran. As a child, he was exposed to fre-
quent physical fights between his mother and father and was often the victim
Epidemiology/Comorbidity/Clinical Presentation: Adults 23

of physical abuse. After completing high school at 18 years of age, Michael

left home and enlisted in the military. He was stationed in Afghanistan and
worked in transportation for 4 years. One morning, while transporting mate-
rials in a convoy, an improvised explosive device (IED) went off in the road.
As Michael was swerving to miss the explosion, he saw that the IED hit the
truck ahead of him, and he knew his fellow soldiers were injured. He later
found out that one of them died in the explosion. Immediately after the
event, Michael began having difficulty sleeping and had nightmares related
to the explosion. Within a few weeks, he also began to have daily intrusions,
was easily startled, began to withdraw from social activities, and reported
feeling very little connection with others. Two months later, Michael was dis-
charged from the military and returned home. Upon his return, he contin-
ued to suffer from his symptoms of PTSD. He began drinking, first to help
him sleep at night, but over the years, he began drinking during the day. One
day, when Michael was in a doctor’s appointment with his primary care physi-
cian, his doctor began to inquire about his experiences in the military and
his drinking habits. The doctor then referred him to the mental health clinic,
where he completed an intake evaluation and was diagnosed with PTSD and
co-­occurring alcohol dependence. During the intake, Michael denied need-
ing treatment, and it was not until 2 years later, after his employer reported
concerns about his mental health, that he finally engaged in treatment.
Michael’s case is a prototypical example of an individual with PTSD
and a co-­occurring substance use disorder. After encountering a traumatic
event, he began experiencing symptoms of PTSD, including having trouble
sleeping, nightmares, intrusions, and withdrawing from others. To help cope
with his symptoms, Michael began to use alcohol. His symptoms remained
undiagnosed for 4 years, until a medical professional recognized a potential
psychological issue. Despite receiving an intake evaluation, it took another 2
years before Michael actually enrolled in treatment.

Conclusion

The epidemiology of trauma and PTSD is relatively new, with the first
national general population-­based studies published only in the early 1990s
(e.g., Resnick, Kilpatrick, Dansky, Saunders, & Best, 1993). Since that time,
epidemiology has made at least four major contributions to our understand-
ing of the population burden of trauma and PTSD. First, trauma exposure
is common and not randomly distributed in the population. Factors both
within the individual and the social context contribute to exposure. Second,
some persons exposed to trauma will go on to have PTSD and this, also, is
dependent on individual and contextual risk factors. Third, PTSD is a highly
prevalent, chronic, and debilitating disorder that is not only often comorbid
with other mental and behavioral disorders such as depression, anxiety, and
SUDs, but also increases the risk of adverse physical health outcomes such
24 Introduction and Background

as CVD (Gradus et al., 2019). Fourth, the majority of individuals with PTSD,
whether in high- or low-­income countries, goes untreated. This is particu-
larly tragic, given the major strides that have been made in our knowledge of
how to treat PTSD—and even prevent PTSD among the trauma-­exposed—­as
is evidenced in this volume. The challenge ahead for epidemiology is to
develop tools to improve our ability to identify persons at risk of PTSD to
target prevention and treatment efforts (Shalev et al., 2019).

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C H A P TE R 3

Epidemiology, Clinical Presentation,

and Developmental Considerations
in Children and Adolescents
Eva Alisic, Rowena Conroy, and Siri Thoresen

A majority of children worldwide are exposed to at least one traumatic

experience while growing up. Although exposure can happen anywhere,
for certain trauma types there are strong ties to children’s characteristics
and context. In addition, just as the types of traumatic exposure are diverse
and multifaceted, children’s responses to trauma exposure are widely varying
as well. Although the focus of this book is on posttraumatic stress disorder
(PTSD), children may also develop other disorders and difficulties, includ-
ing depression, anxiety, and externalizing behavior problems, with a wide
range of adverse developmental and functional outcomes. In the present
chapter, we give a brief overview of current knowledge regarding trauma
exposure and its consequences among children and adolescents; consider
how developmental, systemic, and other contextual factors can affect chil-
dren’s exposure and reactions to trauma; and close with considerations
regarding the limitations of our current evidence base.

Exposure to Traumatic Events

According to DSM-5 (American Psychiatric Association, 2013, p. 271), a

traumatic event for a child or adolescent is a threat-­related event(s). The
event may involve death, assault, community or family violence, child abuse,
any form of sexual assault, accidental or natural disaster, war, or terrorism.
It may be experienced directly, witnessed, or happen to a close loved one.
An often-cited study from the United States (Copeland, Keeler, Angold, &

30
Epidemiology/Clinical Presentation/Developmental Considerations: Children and Adolescents 31

Costello, 2007) found that 68% of 16-year-olds in a large population sample

had experienced at least one traumatic event. McLaughlin and colleagues
(2013) similarly found that 62% of over 6,000 U.S. adolescents had expe-
rienced trauma. In both studies, about half of the trauma-­exposed youth
had experienced two or more events. In other countries, exposure rates are
substantial as well. For example, 31% of young people in England and Wales
reported trauma exposure by age 18 years (Lewis et al., 2019), and among
Swiss adolescents the exposure rate was 56% (Landolt, Schnyder, Maier,
Schoenbucher, & Mohler-­Kuo, 2013).
Although exposure to trauma is a common experience in childhood, it
comes in many substantially different forms. A key distinction made in the
literature is between noninterpersonal and interpersonal types of trauma.
Noninterpersonal trauma includes experiences such as accidents, disaster,
sudden loss of a loved one due to accidental injury, and other unintentional
harm. Sudden loss of a loved one, particularly the death of a parent or sib-
ling, is a frequently reported potentially traumatic life event in childhood
(Landolt et al., 2013; see also Gunaratnam & Alisic, 2017, for an overview).
McLaughlin and colleagues (2013) found that 28% of their sample had
experienced the unexpected death of a loved one. Serious accidental injury
is also common, often caused by motor vehicle crashes, drowning, burns,
or falls (Elklit & Frandsen, 2014; Ghazali, Elklit, Balang, Sultan, & Kana,
2014; World Health Organization, 2014). Disasters are another example of
a noninterpersonal trauma, the frequency, scale, and impact of which are
all expected to increase in the next few decades (United Nations Office for
Disaster Risk Reduction, 2015).
Interpersonal types of trauma include experiences of intentional harm
such as physical violence experienced and/or witnessed within family and
community contexts, sexual violence and abuse, terrorism, and war. The
extent of children’s exposure to violence in peacetime situations is probably
substantially underreported, especially with regard to sexual violence (Saun-
ders & Adams, 2014). Nevertheless, the reported exposure rates are high.
For example, in the National Survey of Children’s Exposure to Violence in
the United States, 24.5% of the children and adolescents had witnessed vio-
lence, 37.3% had experienced a physical assault, 15.2% had been exposed to
any type of maltreatment by caregivers (including physical abuse, emotional
abuse, neglect, and custodial interference), and 1.4% had been sexually
assaulted in the past year (Finkelhor, Turner, Shattuck, & Hamby, 2015). By
late adolescence, 26.6% of U.S. girls and 5.1% of boys report sexual abuse or
assault (Finkelhor, Shattuck, Turner, & Hamby, 2014). A Swiss study showed
that 40.2% of female and 17.2% of male adolescents reported at least one
incident of (contact or no-­contact) child sexual assault (Mohler-­Kuo et al.,
2014). Adolescents ages 15–19 years in major cities in South Africa, Nigeria,
India, and China reported high rates of physical and sexual violence, with
the prevalence of past-year intimate partner violence ranging from 10.2% in
Shanghai to 36.6% in Johannesburg (among female adolescents who ever had
32 Introduction and Background

a partner; Decker et al., 2014). When considering rates of exposure to other

forms of interpersonal trauma, terrorism, and war, these involve high rates
of exposure in specific groups or regions. The number of forcibly displaced
people is nearing 71 million worldwide (United Nations High Commissioner
for Refugees, 2019), with about 50% of all refugees being children.
Although any child may be exposed to trauma, not every child is at
equal risk; exposure is related to a range of factors. On an individual level,
several factors stand out. For example, looking at demographics, trauma
exposure varies with developmental stage. Overall, older children show
higher lifetime, and in many cases higher 12-month, exposure rates than
younger children, likely because they are more likely to participate in inde-
pendent activities and have had more time to have been exposed (Alisic, van
der Schoot, van Ginkel, & Kleber, 2008; Copeland et al., 2007; Finkelhor,
Ormod & Turner, 2009). A few types of trauma, however, such as acciden-
tal burn injuries, are more common among younger children (Stoddard et
al., 2006). Girls are more at risk of certain types of trauma exposure, such
as sexual violence, compared to boys (Finkelhor et al., 2015; Landolt et al.,
2013; Salazar, Keller, Gowen, & Courtney, 2013), who are more at risk of
experiencing community physical violence and accidental injury (Landolt
et al., 2013; McLaughlin et al., 2013). Children with externalizing behavior
problems, disabilities, and other “otherness” (i.e., ways in which children
may be different in terms of appearance, behavior, or background) appear
to be at higher risk of accidents and violent exposure (McLaughlin et al.,
2013; Owens, Fernando, & McGuinn, 2005). At a family level, low socio-
economic status and/or difficulties related to family functioning, such as
mental health problems, drug abuse, or marital conflict, may put a child at
increased risk of exposure (e.g., due to lack of supervision, Morrongiello &
House, 2004; Schwebel & Gaines, 2007). At the community and country level,
socioeconomic disadvantage also represents a risk factor: neighborhoods
with high crime rates involve, logically, higher risk for children of exposure
to violence (Irie, Lang, Kaltner, Le Brocque, & Kenardy, 2012), and children
living in low-­income countries are at higher risk of disaster and conflict (e.g.,
see Demyttenaere et al., 2004).
Moreover, exposure appears to come in clusters: initial exposure, in
particular to violence, increases the risk of further exposure, both in the
near and distant future (Aakvaag, Thoresen, Wentzel-­Larsen, & Dyb, 2017;
Finkelhor et al., 2015; Updegrove & Muftic, 2019). Childhood physical and
sexual abuse commonly co-occur with other types of child maltreatment—­
namely, emotional abuse and neglect—­and with other forms of dysfunction
or difficulty within the home (e.g., parental intimate partner violence, care-
giver mental health problems or substance abuse, criminal activity; see Dong
et al., 2004; Finkelhor, Ormond, & Turner, 2007; Hamby, Finkelhor, Turner,
& Ormrod, 2010). Indeed, exposure to multiple types of trauma and adver-
sity is the norm for children who have been maltreated (e.g., Dong et al.,
2004). The range of adversities to which maltreated children are exposed do
Epidemiology/Clinical Presentation/Developmental Considerations: Children and Adolescents 33

not always fulfill the above-­mentioned criteria for a traumatic stressor but
are nonetheless associated with adverse psychological and developmental
outcomes (e.g., Taillieu, Brownridge, Sareen, & Afifi, 2016) that may com-
pound the effects of exposure to traumatic stressors.

Consequences of Trauma Exposure

Although this book focuses on PTSD, it is critical to acknowledge that there

is a range of potential consequences of traumatic exposure for children. In
this chapter, we discuss the negative mental health consequences that have
received most empirical attention, and some of the associated functional
difficulties that children and adolescents can experience. In terms of mental
health, we discuss PTSD, acute stress disorder (ASD), depression, prolonged
grief disorder, anxiety, and externalizing behavior problems. With regard to
associated difficulties, we focus on physical health problems and academic
difficulties. Importantly, there are high levels of comorbidity: children and
adolescents often experience multiple difficulties at the same time (e.g.,
Copeland et al., 2007).

Mental Health Problems

The range of documented mental health problems in youth after trauma is
vast. Over the past few decades, there has been increased recognition of dif-
ferences between children and adults in terms of the nature and expression
of trauma-­related mental health difficulties (e.g., Scheeringa, Zeanah, &
Cohen, 2011). There is substantial debate about the extent to which current
diagnostic classification systems adequately capture the wide range of diffi-
culties that children experience (e.g., Cohen & Scheeringa, 2009; D’Andrea,
Ford, Stolbach, Spinazzola, & van der Kolk, 2012; Goldbeck & Jensen, 2017).
Here, we focus largely on those mental difficulties currently described by
the major classification systems (i.e., the DSM and ICD).

Posttraumatic Stress Disorder

In DSM-5, diagnostic criteria for PTSD in older children (ages 6 years and
over) are the same as they are for adults, with PTSD conceptualized and
diagnosed as a four-­ factor model of symptoms: reexperiencing of the
trauma, persistent avoidance of trauma-­related stimuli, negative alterations
in cognition and mood, and hyperarousal and reactivity. There are some
developmental specifiers within the text of DSM-5 in recognition of the fact
that children’s traumatic stress reactions can manifest differently from those
of adults. For example, it is noted that intrusive memories may be shown via
repetitive, trauma-­t hemed play, and that nightmares may not have recogniz-
able content (American Psychiatric Association, 2013).
34 Introduction and Background

For younger children (under the age of 6 years), there is a separate set
of diagnostic criteria, developed in response to research showing marked
developmental differences in how posttraumatic stress reactions are mani-
fest in the preschool period (see Scheeringa et al., 2011). This represents
the first developmental subtype of a disorder of any kind in the DSM. In
this “preschool” subtype, avoidance and negative alterations in cognition/
mood combine into a single symptom cluster. In addition, some symptoms
that appear in the criteria for older children and adults are excluded (e.g.,
cognitive symptoms that preschoolers are unlikely to display or describe,
such as negative beliefs about the self/world/future, and persistent blame
of self/others). Furthermore, within the preschool subtype criteria there is
explicit recognition that some symptoms may present differently in this age
group than in older children/adults. For example, it is noted that “spontane-
ous and intrusive memories may not necessarily appear distressing” and that
“diminished interest in significant activities” may be reflected in “constric-
tion of play.”
ICD-11 (World Health Organization, 2018) uses a three-­factor model
for PTSD, such that to meet criteria, an individual (child or adult) must
show core symptoms of reexperiencing of the trauma, avoidance of trauma
reminders, and arousal/reactivity. In ICD-11, a diagnosis of complex PTSD
can also be made when an individual meets the aforementioned criteria for
PTSD and also shows prominent features of affect dysregulation, negative
self-­concept (accompanied by feelings of shame, guilt, or failure related to
the trauma), and interpersonal problems.
Current estimates are that, overall, approximately 16% of children
and adolescents exposed to trauma develop PTSD (Alisic et al., 2014),
with higher rates for interpersonal trauma compared to noninterpersonal
trauma. Children typically follow one of three to four trajectories (e.g., Le
Brocque, Hendrikz, & Kenardy, 2010; Miller-­Graff & Howell, 2015; although
see also Nugent et al., 2009). The first trajectory (“resilience”) is one of con-
sistently low levels of distress. The second (“recovery”) group experiences
acute stress, which resolves over time. The third (“chronic”) experiences con-
sistent and persistent high levels of distress. The fourth (“delayed” onset)
experiences subclinical initial levels of distress but develops clinically signifi-
cant symptoms over time. This fourth trajectory (Punamäki, Palosaari, Diab,
Peltonen, & Qouta, 2015) does not always appear in studies among children,
in contrast to studies among adults (e.g., see Smid, Mooren, van der Mast,
Gersons, & Kleber, 2009). Over half of children fall into the resilient group,
a quarter to a third into the recovery group, and a small percentage into
the chronic group. This pattern is very similar to trajectories seen in adults
(e.g., see Bonanno, 2005). Importantly, while on average, symptom levels in
trauma-­exposed children decline over the first 6 months posttrauma, there
is little evidence that natural recovery occurs beyond 6 months, suggesting
that it is unlikely a child would recover from PTSD without intervention at
that point (Hiller et al., 2016).
Epidemiology/Clinical Presentation/Developmental Considerations: Children and Adolescents 35

It is still difficult to predict which children will end up on which trajec-

tory (see also Gunaratnam & Alisic, 2017). In terms of preexisting factors,
in contrast to their role in risk for exposure, demographic factors, such as
gender, age, race, and socioeconomic status, do not seem to play particularly
important roles in predicting a child’s level of distress posttrauma (Alisic,
Jongmans, Van Wesel, & Kleber, 2011; Scheeringa et al., 2011; Trickey, Sid-
daway, Meiser-­Stedman, Serpell, & Field, 2012). Prior exposure to trauma
does, however, play an important role (Catani, Jacob, Schauer, Kohila, &
Neuner, 2008; Cox, Kenardy, & Hendrikz, 2008; McLaughlin et al., 2013).
Similarly, prior mental health difficulties and family functioning are predic-
tors of PTSD (e.g., see Cox et al., 2008; McLaughlin et al., 2013). In terms
of peritrauma factors, a key predictor of PTSD is the nature of the exposure;
interpersonal trauma is much more likely to lead to PTSD than noninterper-
sonal trauma (pooled PTSD rates of 25% vs. 10% in a meta-­analysis; Alisic et
al., 2014), and separation from family is a risk factor as well (McFarlane, 1987;
McGregor, Melvin, & Newman, 2015). Biological variables during or shortly
after exposure, such as increased heart rate and cortisol levels, appear to
be predictive (Nugent, Christopher, & Delahanty, 2006; Pervanidou, 2008),
although the effect sizes found have been small. Cognitions during or after
the exposure, such as the experience of life threat or the feeling of perma-
nent and disturbing change, show much stronger associations with subse-
quent PTSD (Meiser-­Stedman, Dalgleish, Gluckman, Yule, & Smith, 2009;
Trickey et al., 2012). In terms of posttrauma factors, those related to parental
adjustment—­namely, parents’ own posttrauma coping, stress reactions, and
mental health—­seem to matter a great deal for the child’s ability to heal
(Alisic et al., 2011; Cox et al., 2008; Landolt, Ystrom, Sennhauser, Gnehm,
& Vollrath, 2012; Marsac, Donlon, Winston, & Kassam-­Adams, 2013). Social
support seems to be protective against PTSD for children and adolescents
(e.g., Langley et al., 2013; Trickey et al., 2012).

Acute Stress Disorder

ASD, according to DSM-5 criteria, is diagnosed if a child/adolescent dis-
plays a high level of symptomatology (associated with impairment in func-
tioning) between 3 days and 1 month following a trauma, with symptoms
in the following domains: reexperiencing, avoidance, negative alterations
in cognition/mood, arousal/reactivity, and/or dissociation. ICD-11 does
not include an equivalent classification; acute stress is instead considered
a normal reaction to a traumatic event. Research on ASD in children and
adolescents has occurred mostly within the accidental injury context. In this
setting, concerns have been raised about the sensitivity of DSM criteria for
children. For example, Kassam-­Adams and colleagues (2012) combined data
from 15 hospital-­based studies in the United States, the United Kingdom,
Australia, and Switzerland; they found that 41% of children and adolescents
experienced clinically relevant impairment, yet only 12% met criteria similar
36 Introduction and Background

to the current ASD criteria. Recent data suggest that ASD does not function
as a “catch-all” for identifying those at risk of persistent posttraumatic men-
tal health difficulties (e.g., see Meiser-­Stedman et al., 2017). A more broad-
based assessment that includes depression may be a more effective approach
to identifying young people at risk of later difficulties, though this is yet to
be fully tested.

Prolonged Grief Disorder

Increased attention has been given in recent years to understanding the
bereavement-­related psychological difficulties experienced by youth when
their trauma exposure involves the death of someone close to them (e.g.,
Kaplow, Layne, Pynoos, Cohen, & Lieberman, 2012). Indeed, in response to a
traumatic death, approximately 10% of children develop prolonged or “com-
plicated” grief reactions that are distinct from bereavement-­related PTSD,
anxiety, and depression (e.g., Dillen, Fontaine, & Verhofstadt-­Deneve, 2009;
Melhem, Moritz, Walker, Shear, & Brent, 2007; Melhem, Porta, Shamsed-
deen, Walker Payne, & Brent, 2011; Spuij et al., 2012). These responses are
associated with significant functional impairment and are typically charac-
terized by intense yearning, difficulty accepting the loss, prominent anger,
and a sense that life is meaningless. The DSM does not yet recognize such
difficulties by way of a formal diagnostic category, but “persistent complex
bereavement disorder” has been listed in the “conditions for further study”
section of DSM-5 (American Psychiatric Association, 2013). In ICD-11, a
formal diagnostic category has been introduced to describe bereavement-­
related reactions that warrant clinical attention—­namely, prolonged grief
disorder (PGD). Core symptoms include longing for and preoccupation with
the deceased, together with emotional distress and impaired functioning
that persist beyond 6 months after the person’s death and go beyond what is
normal in one’s culture.

Depression
Research with children exposed to a range of trauma types has shown that
clinically significant levels of depression frequently co-occur with PTSD
(see Goenjian et al., 2009; Lai, Auslander, Fitzpatrick, & Podkowirow, 2014;
Scheeringa, 2015). Studies reveal wide variability in rates of depression, but
with rates often found to be greater than those in the general population. Lai
and colleagues (2014), for example, found that studies examining depression
in youth following natural disasters reported rates of depression from 2 to
69% compared to typical ranges of 1–9% in general population studies. In
an accidental injury sample, Kassam-­Adams, Bakker, Marsac, Fein, and Win-
ston (2015) found that 13% of 8- to 17-year-old participants displayed clini-
cally significant levels of depression. Meiser-­Stedman and colleagues (2017)
found that 23.4% of children exposed to a single-­incident trauma resulting
Epidemiology/Clinical Presentation/Developmental Considerations: Children and Adolescents 37

in emergency department visits experienced substantial depression symp-

toms that were largely stable and persistent across time.

Anxiety
Symptoms of anxiety, as indexed via continuous symptomatology measures,
have been shown to co-occur with PTSD in trauma-­exposed youth across
several studies (e.g., La Greca, Danzi, & Chan, 2017; La Greca et al., 2013).
Questions remain, though, regarding whether such findings are best con-
ceptualized as capturing symptom overlap with PTSD, or representing the
presence of a distinct form of psychopathology (see Cohen & Scheeringa,
2009; Scheeringa, 2015). In a preschool sample, Scheeringa (2015) found
that 11% of those exposed to Hurricane Katrina, 18% of those exposed to
other single-­incident traumas, and 16% of those exposed to repeated trauma
(mainly domestic violence) developed an anxiety disorder (either separation
anxiety disorder, generalized anxiety disorder, or social phobia). Very few,
however, had anxiety disorders in the absence of PTSD, raising important
questions about the mechanisms underlying development of anxiety follow-
ing trauma.
Relatively limited empirical data are available regarding the prevalence
of specific anxiety disorders in trauma-­exposed youth. Hoven and colleagues
(2005) studied the mental health of children living in New York City in the
aftermath of September 11, 2001, and found that, 6 months after the terror-
ist attack, probable agoraphobia (14.8%) and separation anxiety disorder
(12.3%) were most prevalent, even more than PTSD (10.6%). Generalized
anxiety disorder was also quite frequently reported among this group of
children (10.3%). Kim and colleagues (2009) conducted a study 6 months
after a fire escape drill that resulted in a fatal accident and found that ago-
raphobia was the most prevalent DSM-IV anxiety disorder (22.4%), followed
by generalized anxiety disorder (GAD; 13.8%), separation anxiety disor-
der (SAD; 6.9%), PTSD (5.2%), and social phobia (5.2%). Using subclini-
cal cutoff points, however, SAD was the most common (41.4%), followed by
agoraphobia (34.5%), obsessive–­compulsive disorder (OCD; 22.4%), PTSD
(20.7%), and social phobia (20.7%).

Externalizing Behavior
Whereas PTSD, depression, and anxiety are examples of internalizing prob-
lems, trauma-­exposed children may also exhibit externalizing behavior prob-
lems (Whitson & Connell, 2016), such as defiant or oppositional behavior (Li
et al., 2016), conduct problems (Reigstad & Kvernmo, 2016), and symptoms
of attention-­deficit/hyperactivity disorder (Hunt, Slack, & Berger, 2017). In
adolescence, interpersonal violence and child maltreatment are associated
not exclusively with PTSD and depression, but as well with delinquency, sub-
stance abuse, and risky sexual behaviors (Cisler et al., 2012; Jones et al., 2010;
38 Introduction and Background

Yoon, Kobulsky, Yoon, & Kim, 2017). In line with these behaviors, level of
drinking among adolescents has been related to maltreatment and violence
during childhood, and externalizing behavior may represent a pathway
between the two (Cornelius, De Genna, Goldschmidt, Larkby, & Day, 2016;
Proctor et al., 2017).
Regarding the pathway from maltreatment to behavior problems, physi-
cal abuse may be more closely linked with behavioral problems and emo-
tional abuse more closely with emotional problems (Li et al., 2016), but this
is uncertain, and emotional abuse may also increase the risk of externaliz-
ing symptoms, for both girls and boys (Hagborg, Tidefors, & Fahlke, 2017).
Several studies of children make use of both child self-­report and parental
report, and the relationship between maltreatment and adjustment seems
to vary with the informant (Sternberg et al., 1993). Fortunately, there are
indications that safe relationships with teachers (or other “safe adults”) and
other children can protect against the development of behavior problems in
abused children (Ban & Oh, 2016). In addition, improvement in behavioral
problems over time is likely with proper care (Whitson & Connell, 2016).

Other Difficulties: Functional Outcomes

Revictimization as an Outcome
An alarming finding is that children and adolescents exposed to interper-
sonal violence are at increased risk of experiencing new violence (revictim-
ization), not only later in their childhood but also as adults (Finkelhor et al.,
2007). The risk of sexual revictimization following child sexual abuse has
long been known (Arata, 2002), but more recently it has been shown that vic-
timization by any child violence leads to substantial vulnerability for revic-
timization through other types of trauma (Finkelhor et al., 2007). This risk
of revictimization is not a very distant threat, and studies have found that
about one-third of young people exposed to childhood violence experienced
revictimization in a 12- to 18-month time frame (Strøm, Kristian Hjemdal,
Myhre, Wentzel-­Larsen, & Thoresen, 2017). This knowledge, combined with
the well-­documented cumulative health effects of trauma, calls for increased
attention to the future safety of violence-­exposed children. For adults and
clinicians who try to help traumatized children, building safety may be just
as important as alleviating current symptoms.

Physical Health Problems

Although there is compelling evidence that childhood maltreatment
increases the risk of adult mental and physical health problems, little
research has focused on children and adolescents’ somatic complaints follow-
ing trauma while they are still young. Nevertheless, headaches, migraines,
and stomachaches have been associated with community violence (Bailey
et al., 2005) and with interpersonal violence in childhood (Stensland, Dyb,
Epidemiology/Clinical Presentation/Developmental Considerations: Children and Adolescents 39

Thoresen, Wentzel-­Larsen, & Zwart, 2013). Furthermore, trauma and inter-

personal violence seems to increase the risk of eating disorders (Trottier
& ­ MacDonald, 2017), overweight (Oh et al., 2018; Stensland, Thoresen,
Wentzel-­Larsen, & Dyb, 2015), chronic pain (McLaughlin et al., 2016), and
musculoskeletal problems (Dirkzwager, Kerssens, & Yzermans, 2006; Dorn,
Yzermans, Spreeuwenberg, Schilder, & van der Zee, 2008). In a commu-
nity study of preschool children experiencing poverty, exposure to domes-
tic violence was one of the strongest predictors of somatic health problems
(Graham-­Bermann & Seng, 2005).
Adverse somatic outcomes following traumatic events have predomi-
nantly been considered products of posttraumatic stress (Pacella, Hruska, &
Delahanty, 2013). However, it has also been argued that somatic problems in
children are underrecognized because they are understood as secondary to
psychological symptoms (Hensley & Varela, 2008). We do not yet fully under-
stand the interplay between physical and mental health problems following
trauma and violence in childhood. Nevertheless, somatic health problems in
the aftermath of violence or trauma can affect the child’s ability to attend
school, take part in leisure activities, and engage in social relationships.

Difficulties in School or Academic Performance

Both acute and chronic traumatic events seem to have a negative impact on
cognitive functioning, academic results, and social and emotional behavior
in school (Perfect, Turley, Carlson, Yohanna, & Saint Gilles, 2016; Veltman
& Browne, 2001). In the acute trauma context, for example, primary school
children affected by disaster can show decreased academic performance
over time, particularly in the domains of mathematics and reading (Gibbs
et al., 2019). Childhood abuse has also been linked to problems with cogni-
tive functioning and lower academic performance (Crozier & Barth, 2005;
Kendall-­Tackett & Eckenrode, 1996; Veltman & Browne, 2001), in terms of
grades, test scores, and school absences (Leiter & Johnsen, 1994). Learn-
ing difficulties in abused or neglected children can relate to their behav-
ior difficulties, which may also vary with the type of abuse to which they
have been exposed. For example, neglected children may show less social
interaction with their classmates, whereas physically abused children may
display aggressive behavior (Hoffman-­Plotkin & Twentyman, 1984). Likely, a
child’s potential problems at school will be influenced by the type of home
environment they experience, including the type and intensity of maltreat-
ment they have undergone (Pears, Kim, & Fisher, 2008). Long-term studies
are few, but violence and abuse reported at age 15 has been found to pro-
spectively predict high school dropout, work marginalization, and long-term
welfare benefits 10 years later (Strøm, 2014). Maintaining school attendance
and educational support over time seems to be of importance for children
exposed to maltreatment and other forms of trauma, and a close coopera-
tion between clinicians, educators, and parents seems warranted (Strøm,
Schultz, Wentzel-­Larsen, & Dyb, 2016).
40 Introduction and Background

Caveats about Current Epidemiological

and Clinical Knowledge

Although it is well established that following trauma exposure, children of

all ages can develop persistent difficulties, many aspects of child adaptation
posttrauma are still underresearched or not well understood. For example,
there is still a dearth of research on children in low- and middle-­income
countries, and on children from minority groups in high-­income countries.
We also have more knowledge of children in some age groups compared to
other age groups: very young children are still underresearched, although
research activity is increasing (e.g., De Young, Kenardy, & Cobham, 2011;
Haag & Landolt, 2017). Similarly, when looking at family factors, we have
substantially more knowledge that relates to children’s mothers than to their
fathers.
Although there is a substantial body of knowledge regarding child
PTSD, research into other child health and well-being outcomes is sparse.
Some prevalence data are available; future studies should generate insights
regarding other aspects of posttrauma depression, grief, and other disor-
ders among children, including their predictors and trajectories, and mech-
anisms underlying the high levels of comorbidity often seen (see also Cohen
& Scheeringa, 2009; Scheeringa, 2015). Moreover, traditionally there has
been a strong focus on disorders, whereas recently researchers have increas-
ingly started to collect data on children’s functioning in daily life.
Methodologically, a few caveats should be noted. First, a recurring ques-
tion in child psychotraumatology is who serves as “informant” regarding
a child’s well-being: the child and/or the parent, or a third party, such as
a teacher? Reports that build solely on parents’ perspectives are known to
underreport children’s symptoms (e.g., Daviss et al., 2000), leading to rec-
ommendations to make use of combined parent and child reports when
possible (Meiser-­Stedman, Smith, Glucksman, Yule, & Dalgleish, 2007), and
otherwise to use child reports as much as available. Second, much research
has relied on self-­report of mental health experiences and behaviors. Recent
studies endeavor to broaden this type of evidence gathering by including
both biological and behavioral data (e.g., Alisic et al., 2017; Bicanic et al.,
2013; Marsac & Kassam-­Adams, 2016). Finally, many studies are still cross-­
sectional, which makes it difficult to build an understanding of children’s
and families’ trajectories of recovery, and the various factors that play a role
in it.

Conclusion

Trauma is a common and painful experience for children and adolescents

throughout the world. Although some trauma-­ exposed children remain
healthy, such experiences leave lasting emotional footprints for other
Epidemiology/Clinical Presentation/Developmental Considerations: Children and Adolescents 41

children, and the negative consequences for health and well-being have a
high societal cost. Some trauma-­exposed children and adolescents will carry
a burden of emotional distress and physical health problems into adult-
hood and even into old age. Whereas a substantial knowledge base exists
regarding exposure to, and consequences of, trauma among children and
adolescents, the mechanisms involved in the development of these long-term
adverse outcomes need more empirical attention. Most of our knowledge is
currently based on a fraction of the children and adolescents around the
world; as such, cultural and societal differences in how children react to
trauma are still poorly understood. There is still a lot to discover regarding
how children’s and families’ biological and behavioral characteristics predict
their trajectories with respect to the wide range of posttrauma responses and
their interactions. For clinicians, it is clear that staying open to a wide range
of potential outcomes is important when working with trauma-­ exposed
youth, so that relevant evidence-­based assessments and interventions can be
implemented.

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C H A P TE R 4

Diagnosis, Assessment, and Screening

for PTSD and Complex PTSD in Adults
Jonathan I. Bisson, Chris R. Brewin, Marylene Cloitre,
and Andreas Maercker

PManual
osttraumatic stress disorder (PTSD) was first formally recognized as a
diagnosable condition in the third edition of the Diagnostic and Statistical
of Mental Disorders (DSM) classification system (American Psychi-
atric Association, 1980), with the International Classification of Diseases and
Related Health Problems (ICD) following suit in 1992 (World Health Organi-
zation, 1992). The definition and conceptualization of PTSD have changed
over the years, and this chapter considers the current situation with DSM-5
(American Psychiatric Association, 2013) and ICD-11 (World Health Orga-
nization, 2018). To facilitate understanding of many of the key issues con-
cerning the classification of traumatic stress symptoms, a particular focus is
on the development of the parallel diagnoses of PTSD and complex PTSD
(CPTSD) in ICD-11, with the World Health Organization having taken an
arguably more radical and innovative approach to its latest revision than the
American Psychiatric Association. Commonly used instruments designed to
assess DSM-5 PTSD and ICD-11 PTSD and CPTSD are also considered along
with screening for PTSD/CPTSD.

DSM‑5 PTSD

The fifth edition of DSM (DSM-5) was published in 2013 (American Psy-
chiatric Association, 2013), replacing DSM-IV (American Psychiatric Asso-
ciation, 1994) and introducing some important changes to the previous
requirements for diagnosis of PTSD. The symptom clusters comprising
reexperiencing and hyperarousal have undergone minor amendments, with

49
50 Introduction and Background

avoidance symptoms now included as a symptom cluster on their own. Other

key changes include an increase in the total number of symptom criteria to
be considered from 17 to 20, significant changes to the traumatic stressor
criterion, and the introduction of a new cluster of symptoms defined as
“negative alterations in cognitions and mood that are associated with the
traumatic event(s).” There is also a greater emphasis on the symptoms being
definitely related to the traumatic event(s), and PTSD is now described as a
“trauma and stress-­related disorder” as opposed to an anxiety disorder. The
full criteria for DSM-5 PTSD are available in DSM-5 (American Psychiatric
Association, 2013).
DSM-5 has introduced a “with dissociative symptoms” subtype if deper-
sonalization or derealization is present; it allows classification of a “with
delayed expression” subtype if the full symptom criteria are not met until
at least 6 months after the event. PTSD symptoms usually arise soon after
the event (e.g., Galatzer-­Levy & Bryant, 2013; Peleg & Shalev, 2006), but in
a minority of cases, the diagnostic threshold may not be met until beyond
6 months after the traumatic event (“delayed PTSD”). In these cases, clini-
cally significant PTSD symptoms can emerge following strong reminders
or other life stressors (Andrews, Brewin, Philpott, & Stewart, 2007). DSM-5
also includes a preschool (6 years or younger) PTSD subtype with separate
symptom criteria, which are discussed by Berliner, Meiser-­Stedman, and
Danese (Chapter 5, this volume).
In DSM-IV, the traumatic stressor criterion required that individuals
had to experience horror, helplessness, or fear at the time of the event. It has
been removed in DSM-5, given concerns about its utility and its prevention
of some individuals being diagnosed with PTSD despite clearly experiencing
the full symptom criteria following severe traumatic events (Bedard-­Gilligan
& Zoellner, 2008). The description of qualifying traumatic events is more
specific than in DSM-IV, resulting in greater clarity but also excluding a
number of highly traumatic experiences that could previously have led to a
diagnosis of PTSD (e.g., hearing about the unexpected death of a close fam-
ily member as a result of a sudden medical event such as a heart attack). The
reexperiencing and avoidance symptoms are relatively unchanged, but the
two deliberate avoidance symptoms are now contained within a separate cri-
terion, and avoidance is therefore an absolute requirement for the diagnosis.
The introduction of the new Criterion D symptom cluster was based on
confirmatory factor analysis (Friedman, Resick, Bryant, & Brewin, 2011) and
moves the DSM definition of PTSD away from being conceptualized primar-
ily as a fear-based disorder, formally recognizing that other emotions such as
shame and guilt may be prominent. More of the Criterion D symptoms over-
lap with the ICD-11 CPTSD disturbances in self-­organization (DSO) symp-
toms than do the other DSM-5 symptom clusters. For example, D symptoms
of persistent and exaggerated negative beliefs about oneself, others, or the
world and of feelings of shame or guilt overlap with ICD-11 DSO cluster
Diagnosis/Assessment/Screening: Adults 51

symptoms related to negative self-­concept, and D symptoms of feelings of

detachment or estrangement from others overlap with ICD-11 interpersonal
disturbances regarding difficulties feeling close to others and maintaining
relationships. The increased arousal criteria in DSM-5 are similar to those
discussed in DSM-IV but now include “reckless or self-­destructive behavior.”
Despite considerable effort to improve on the DSM-IV classification of
PTSD, the DSM-5 classification is still vulnerable to a number of the criti-
cisms commonly leveled at DSM-IV, not least being that the composition of
the symptom clusters is too broad, many thousands of different combina-
tions of symptoms exist that could lead to a PTSD diagnosis, and there are
high levels of comorbidity, all combining to reduce optimal clinical utility
(Brewin, Lanius, Novac, Schnyder, & Galea, 2009; Galatzer-­Levy & Bryant,
2013; Stein, Seedat, Iversen, & Wessely, 2007).
The DSM-5 criteria for PTSD can be considered a further iteration of
DSM-IV, based on empirical evidence and the views of the work group that
oversaw their development. The specification of DSM-5 and ICD-11 was seen
by some as an opportunity to bring the American Psychiatric Association
and World Health Organization definitions closer together (First, 2009;
Jablensky, 2009; Kupfer, Regier, & Kuhl, 2008) or even to make them iden-
tical (Frances, 2009). Indeed, an ICD–DSM Harmonization Coordination
Group was created to facilitate this goal. Interestingly, the two classification
systems have, in fact, diverged with respect to PTSD, and the argument that
the differences in the ICD-10 and DSM-IV classifications of PTSD were defi-
nitional as opposed to conceptual (First, 2009) is not the case for DSM-5 and
ICD-11. Arguably, the fact the main classification systems now offer differ-
ent conceptualizations of PTSD introduces unintended risks, such as inter-
changeable use depending on whether the presence or absence of a diagno-
sis of PTSD is desired, and confusion among people with PTSD and CPTSD,
clinicians, and others (Bisson, 2013).

Assessment of DSM‑5 PTSD

Validated and reliable instruments used to assess DSM-IV PTSD have been
adapted to assess DSM-5 PTSD. For example, the widely used Clinician-­
Administered PTSD Scale (CAPS) for DSM-IV (Weathers, Keane, & David-
son, 2001) has been revised and developed as the CAPS-5 with psychometric
data on it now becoming available (Weathers et al., 2018). Its sibling, self-­
administered measure, the PTSD Checklist (PCL; Blanchard, Jones Alexan-
der, Buckley, & Forneris, 1996), is also now available for DSM-5 PTSD (PCL-
5; Weathers et al., 2013). Both these instruments (their English-­language
versions) are available on request from the U.S. National Center for PTSD
and can be used by appropriately trained clinicians and researchers free
of charge (www.ptsd.va.gov/professional/assessment/dsm-5_validated_measures.
asp).
52 Introduction and Background

Guiding Principles in the Development

of ICD‑11 Diagnoses

Clinical utility is a key principle that has guided the development of the ICD-
11 diagnoses. It refers to the characteristics of a diagnostic system that make
it useful at the level of a clinical encounter (Reed et al., 2019). Health data
for the World Health Organization are collected at the level of the clinical
encounter across all countries and communities. Thus, diagnostic systems
with characteristics such as being overly complex, difficult to understand, or
not clinically relevant are unlikely to be properly or routinely implemented,
leading to underreporting or unreliable reports of diagnoses. For these rea-
sons, ICD-11 guidelines urged that in addition to being scientifically valid,
diagnoses have characteristics that support clinical utility, including that the
diagnoses be limited in number of symptoms, be easily discriminated from
one another, and translate into effective and resource-­efficient treatment
plans (Reed, 2010). The ICD-11 diagnoses that have emerged from this pro-
cess, including PTSD and CPTSD, have been evaluated in clinical settings
in 13 countries and have been assessed by clinicians as having high clinical
utility (Reed, Keeley, et al., 2018). Moreover, the reliability of the ICD-11
diagnoses appear to be at least as high as that obtained by DSM-5 (Reed,
Sharan, et al., 2018).

Rationale for a PTSD and CPTSD Distinction

The rationale for the development of two trauma-­ related disorders was
primarily to account for and organize the heterogeneity of posttraumatic
stress symptoms along conceptual and etiological lines and ultimately to
direct treatment options in a resource-­efficient way. PTSD is articulated as
a trauma-­generated disorder where symptoms focus on reactions to trauma-­
related stimuli as represented in three symptom clusters: reexperiencing of
the traumatic event in the present, avoidance of traumatic reminders, and
a sense of current threat. CPTSD includes not only the symptoms of PTSD
but also problems in self-­organization related to affective, self-­concept and
interpersonal domains that are typically associated with exposure to sus-
tained, repeated, or multiple types of traumas (e.g., childhood sexual abuse,
domestic violence, exposure to sustained civil war or community violence).
CPTSD is composed of six clusters: the three PTSD clusters as well as three
clusters related to disturbances in self-­organization (DSO): affect dysregula-
tion, negative self-­concept, and disturbances in relationships.
The validity of the PTSD/CPTSD distinction has been demonstrated
in several studies indicating that the two disorders consistently differ by
the types of traumas that create risk, by comorbidity burden, and by level
of impairment (see Brewin et al., 2017; Cloitre et al., 2019). Moreover, sev-
eral latent class analyses have found that trauma-­exposed populations fall
into distinct classes by the types of symptoms they report, with one group
Diagnosis/Assessment/Screening: Adults 53

reporting only PTSD symptoms and the other complex PTSD symptoms
(Brewin et al., 2017). These data provide substantial evidence supporting
the validity of the PTSD and CPTSD profiles as distinct disorders.
Certain characteristics of the ICD-11 diagnoses are important to note.
First, diagnosis of PTSD and CPTSD occurs in an either/or fashion. An
individual can have either one or the other diagnosis, not both. If a person
receives the diagnosis of CPTSD, then the individual does not also receive a
PTSD diagnosis. This distinction leads to consistent observations that those
with PTSD have fewer comorbidities and less functional impairment. Some
studies that have viewed CPTSD as a subtype of PTSD have combined both
disorders under one “ICD-11 PTSD” umbrella and reported, misleadingly,
that ICD-11 PTSD is associated with as high or higher rates of comorbidity
as DSM-5. Second, the diagnosis of CPTSD requires functional impairment
that is related to the PTSD as well as the DSO symptom clusters. Lastly, the
diagnoses of PTSD and CPTSD are made by reference to symptoms, not to
type of traumatic event. Type of event is viewed as a risk factor, not a require-
ment for each disorder. This recognizes the potential influence of predispos-
ing factors such as personal and environmental resources (e.g., resilience,
social support) or lack thereof on individual outcomes.

ICD‑11 PTSD
ICD-11 diagnoses are presented in the Clinical Descriptions and Diagnostic
Guidelines (CDDG), a document intended for general clinical, educational,
and service use. The ICD-11 PTSD exposure and symptom description is
shown in Figure 4.1. There is significant overlap with the DSM-5 A, B, C,
and E criteria but also important differences, including the significantly
lower number of symptoms required for the diagnosis and the emphasis on

Posttraumatic stress disorder (PTSD) is a disorder that may develop following

exposure to an extremely threatening or horrific event or series of events that
is characterized by all of the following: (1) reexperiencing the traumatic event
or events in the present in the form of vivid intrusive memories, flashbacks, or
nightmares. These are typically accompanied by strong or overwhelming emotions,
particularly fear or horror, and strong physical sensations; (2) avoidance of
thoughts and memories of the event or events, or avoidance of activities, situations,
or people reminiscent of the event or events; and (3) persistent perceptions of a
heightened current threat, as indicated by hypervigilance or an enhanced startle
reaction to stimuli such as unexpected noises. The symptoms persist for at
least several weeks and cause significant impairment in personal, family, social,
educational, occupational, or other important areas of functioning.

FIGURE 4.1. Definition of ICD-11 PTSD. Used with permission from the World
Health Organization.
54 Introduction and Background

fear and horror. The exposure criterion has been modified from ICD-10 to
remove the statement that it would “cause distress in almost everyone.”
There are context-­dependent presentations and other symptoms typical
of PTSD. In conditions where conscious memory of the event is reduced or
absent, such as after head injury or very early childhood trauma, emotional
or physiological reactivity to trauma reminders may be present instead of
reexperiencing (cf. Harvey & Bryant, 2001). Accompanying the reexperi-
encing core symptoms, strong or overwhelming emotions typically appear.
The most prominent themes are fear or horror in the case of witnessing
traumatic events. Other emotions commonly present in PTSD can be anger,
shame, sadness, humiliation, and guilt, including survivor guilt. The defi-
nition of PTSD requires “functional impairment” to differentiate it from
normal-­range reactions to extreme stressors (Rona et al., 2009) and a dura-
tion of at least several weeks.
Other symptoms that are not essential for the diagnosis of PTSD but
commonly occur in people with it include dissociative symptoms such as
memory disturbances (e.g., dissociative amnesia); pseudo-­ hallucinations
(e.g., hearing one’s own thoughts as voices); somatic complaints without a
medical basis, including headache and dyspnea (cf. Somasundaram & Siv-
ayokan, 1994); suicidal ideation and behavior; and excessive use of alcohol
or drugs to avoid reexperiencing or to manage emotional reactions. The
course of PTSD often fluctuates (Bryant, O’Donnell, Creamer, McFarlane,
& Silove, 2013; Maercker, Gäbler, & Schützwohl, 2013) and may develop into
ICD-11 complex PTSD.

Evidence Base for ICD‑11 PTSD Changes

A major innovation in ICD-11 is the specification of core features rather than
explicit operationalized criteria and an explicit diagnostic algorithm for PTSD.
The specification of core features was based on empirical and theoretical
grounds and was designed to most clearly distinguish PTSD from other dis-
orders. In contrast, features that are typical though not core are commonly
present but are likely to represent general distress or dysphoria rather than
being specific to PTSD, such as irritability, lack of concentration, or feel-
ings of detachment or estrangement from others (Gootzeit & Markon, 2011;
Yufik & Simms, 2010).
Empirical evidence for defining ICD-11 PTSD was drawn primarily
from studies investigating the symptom structure of previous PTSD defi-
nitions (e.g., Gootzeit & Markon, 2011; King, King, Fairbank, Keane, &
Adams, 1998). In addition to intrusions, avoidance, and hyperarousal, a
group of numbing symptoms (amnesia, loss of interest, detachment, and
restricted affect) were found in many of the early factor analyses. For exam-
ple, a comprehensive confirmatory factor analysis (CFA) was conducted with
3,700 U.S. veterans and found a four-­factor solution of intrusions, avoid-
ance, hyperarousal, and dysphoria using 17 DSM-IV-based PTSD symptoms
Diagnosis/Assessment/Screening: Adults 55

(Simms, Watson, & Doebbeling, 2002). The dysphoria factor consisted of

three numbing symptoms and three hyperarousal symptoms. Further inves-
tigation determined that only the dysphoria factor correlated relatively
highly with depression (r = 0.80) and generalized anxiety (r = 0.63), whereas
all other factors were only moderately correlated with other disorders. The
authors concluded that the dysphoria factor was nonspecific to PTSD, a find-
ing supported by a subsequent meta-­analysis of 41 studies conducted with a
total of 61,000 participants (Gootzeit & Markon, 2011).
Evidence also exists that some single symptoms are more specific to
PTSD than others. For example, intrusive memories have been found in clin-
ical samples across a number of mental disorders, including obsessive com-
pulsive disorder (Salkovskis, 1985), depression (Brewin, 1998), social phobia
(Hackmann, Clark, & McManus, 2000), and agoraphobia (Day, Holmes, &
Hackmann, 2004), and have also been noted in nonclinical samples (Brewin,
Christodoulides, & Hutchinson, 1996). In contrast, flashbacks with their
“here-and-now” quality have been confirmed in cross-­ sectional (Bryant,
O’Donnell, Creamer, McFarlane, & Silove, 2011; Duke, Allen, Rozee, & Bom-
maritto, 2008) as well as prospective studies (Michael, Ehlers, Halligan, &
Clark, 2005) to be a particularly sensitive and specific indicator of PTSD.
Posttraumatic nightmares are another distinctive feature of PTSD, occur-
ring in up to 70% of diagnosed individuals (Harvey, Jones, & Schmidt, 2003;
Lamarche & de Koninck, 2007). In a clinical sample with various mental dis-
orders, Swart, van Schagen, Lancee, and van den Bout (2013) found night-
mares to be significantly more common in PTSD (67%) than in depressive
disorders (37%), anxiety disorders (16%), personality disorders (31%), or
psychotic and other disorders (27%).
These findings led to the current ICD-11 conceptualization of PTSD
being developed and published (Maercker, Brewin, et al., 2013), with exten-
sive research between 2013 and 2017 supporting the definition. Brewin and
colleagues (2017) reviewed 27 studies from this period, the majority of which
supported the proposed ICD-11 definition. In particular, the proposed three-­
factor structure of PTSD, operationalized with two core symptoms repre-
senting each factor, provides a very good fit to the data. Although the level of
agreement between the presence or absence of a diagnosis using ICD-11 and
the DSM is generally high, the prevalence of PTSD in adult samples is also
consistently slightly lower when ICD-11, rather than the DSM, is used. This is
consistent with the narrower definition of PTSD in ICD-11.

ICD‑11 CPTSD
The ICD-11 definition of CPTSD and its essential or core features are pre-
sented in Figure 4.2. Core features are those symptoms or characteristics
that “a clinician could reasonably expect to find in all cases of the disorder”
(First, Reed, Hyman, & Saxena, 2015, p. 85). Problems in affect, negative self-­
concept, and interpersonal problems are described in some detail. Problems
56 Introduction and Background

Definition
Complex posttraumatic stress disorder (complex PTSD) is a disorder that may
develop following exposure to an event or series of events of an extremely
threatening or horrific nature, most commonly prolonged or repetitive events from
which escape is difficult or impossible (e.g., torture, slavery, genocide campaigns,
prolonged domestic violence, repeated childhood sexual or physical abuse).
All diagnostic requirements for PTSD are met. In addition, complex PTSD is
characterized by severe and persistent (1) problems in affect regulation; (2) beliefs
about oneself as diminished, defeated, or worthless, accompanied by feelings of
shame, guilt, or failure related to the traumatic event; and (3) difficulties in sustaining
relationships and in feeling close to others. These symptoms cause significant
impairment in personal, family, social, educational, occupational, or other important
areas of functioning.

Diagnostic Guidelines
• Exposure to a stressor typically of an extreme or prolonged nature and from which
escape is difficult or impossible, such as torture, concentration camps, slavery,
genocide campaigns and other forms of organized violence, domestic violence,
and childhood sexual or physical abuse
• Presence of the core symptoms of PTSD (reexperiencing the trauma in the
present, avoidance of reminders of the trauma, and persistent perceptions of
current threat)
• Following onset of the stressor event and co-occurring with PTSD symptoms,
the development of persistent and pervasive impairments in affective, self, and
relational functioning, including problems in affect regulation, persistent beliefs
about oneself as diminished, defeated, or worthless, persistent difficulties in
sustaining relationships
• The stressors associated with complex PTSD are typically of an interpersonal
nature, that is, the result of human mistreatment rather than acts of nature (e.g.,
earthquakes, tornadoes, tsunamis) or accidents (train wrecks, motor vehicle
accidents). In addition to the typical symptoms of PTSD, complex PTSD is
characterized by more persistent long-term problems in affective, self, and
relational functioning. Problems in all three areas often co-occur.

FIGURE 4.2. ICD-11 definition of and guidelines for complex PTSD. Used with per-
mission from the World Health Organization.

in affect dysregulation include both hyperreactivity, such as heightened

emotional reactivity, difficulty recovering from minor stressors, and violent
outbursts, as well as hyporeactivity, such as numbing, difficulty experienc-
ing pleasure or positive emotions, and tendency toward dissociative states
when under stress. Problems in self-­concept include persistent beliefs about
oneself as diminished, defeated, or worthless accompanied by deep and
pervasive feelings of shame, guilt, or failure. Interpersonal problems are
characterized by persistent difficulties in sustaining relationships. Examples
of such difficulties include problems feeling close to others, avoidance of
Diagnosis/Assessment/Screening: Adults 57

relationships, ending relationships when difficulties or conflicts emerge, or

even deriding the value or importance of relationships.
Associated features are symptoms and problems that may be observed
in the individual with CPTSD but are not necessary to making the diagno-
sis. These symptoms and problems help the clinician in recognizing the full
range of symptoms that may be present. In ICD-11 CPTSD, they include
suicidal ideation and behavior and substance abuse, both of which have been
related to difficulties regulating emotions, as well as significant depression
and psychotic episodes. Somatic complaints may be present but vary by cul-
ture and might be the result of the trauma (torture, physical punishment, or
inadequate food, clothing, or shelter).

Differential Diagnosis
One criticism of a complex PTSD diagnosis is that it would not be distin-
guishable from PTSD with borderline personality disorder (BPD). ICD-11
CPTSD and BPD do share conceptual overlap in the type of problems that
are included in each diagnosis, namely, difficulties in affect regulation, self-­
concept, and interpersonal relationships. However, the specific nature of
these difficulties is quite distinct. In BPD, self-­concept difficulties reflect an
unstable sense of self, whereas in CPTSD, they reflect a persistent, negative
view of self. Relational difficulties in BPD are characterized by volatile pat-
terns of interaction, whereas in CPTSD, they reflect a persistent tendency to
avoid relationships. With regard to affect dysregulation, BPD is character-
ized by fears of abandonment and self-­harming/suicidal behavior, and these
symptoms are not part of the DSO profile in CPTSD. Other relevant features
differentiate BPD and CPTSD, most notably the fact that CPTSD requires
the presence of trauma-­specific PTSD symptoms that are not a feature of
BPD; BPD also does not require traumatic exposure for diagnosis. Three
studies have tested and found support for the discriminant validity of ICD-
11 CPTSD and BPD (Cloitre, Garvert, Weiss, Carlson, & Bryant, 2014; Frost,
Hyland, Shevlin, & Murphy, 2018; Knefel, Tran, & Lueger-­Schuster, 2016).

Assessment of ICD‑11 PTSD and CPTSD

Even though ICD-11 CPTSD and PTSD are relatively newly formulated dis-
orders, there are at least two measures that have been developed to identify
them and for which there are validity and reliability data. In line with the
ICD-11 goal of clinical utility, the International Trauma Questionnaire (ITQ;
Cloitre et al., 2018), a self-­report measure, was developed to be brief and eas-
ily implemented. The ITQ includes 12 symptom-­related items, two for each
of the six clusters of symptoms, and an additional six items measuring func-
tional impairment (three associated with the PTSD cluster and three associ-
ated with the DSO cluster). An initial version of the measure included 24
58 Introduction and Background

symptom-­related items to represent the wide range of symptoms described,

particularly as related to the DSO symptoms. Through a repeated process
of testing, including item response theory (IRT) modeling, the number of
symptom-­related items was reduced to 12 (Shevlin et al., 2018). In a recent
survey of a nationally representative sample in the United States (Cloitre et
al., 2019), the reliability (Cronbach’s alpha) of the items was satisfactory for
the full sample (PTSD alpha = 0.89 and DSO alpha = 0.89), among males
(PTSD alpha = 0.88, DSO alpha = 0.89) and females (PTSD alpha = 0.88,
DSO alpha = 0.89). The ITQ has been translated into several languages and
is available for free at www.traumameasuresglobal.com.
An interview measure for ICD-11 PTSD and CPTSD, the International
Trauma Interview (ITI; Roberts, Cloitre, Bisson, & Brewin, 2018), is in devel-
opment and will be posted at the website just cited once testing is complete.

Cross‑Cultural and Supra‑Individual Contexts

for DSM‑5 PTSD and ICD‑11 PTSD/CPTSD

With respect to the cross-­ cultural validity of DSM-5 PTSD and ICD-11
PTSD and CPTSD, the debate is ongoing as to whether the PTSD construct
describes a universal trauma response or if its clinical utility lags behind
that of more regional forms of expressing trauma-­related psychopathology,
including cultural syndromes (Maercker, Heim, & Kirmayer, 2019). Cultur-
ally shaped expressions of symptoms can include a spiritual component, for
example, the sense of heightened current threat may result in distressing
dreams that are interpreted as indicating spiritual insecurity or supernatu-
ral powers seeking out the person in distress (Hinton, Hinton, Pich, Loeum,
& Pollack, 2009; Kwon, 2006, 2008). Several other symptoms seem to be
prominent aspects of PTSD in certain cultural settings, in part because
they are codified into cultural syndromes or “idioms of distress” (Hinton
& Lewis-­Fernandez, 2011; McFarlane & Hinton, 2009)—for example, ohkum-
lang (tiredness) in Bhutanese; susto (fright) among Latino populations; and
kit chraen (thinking too much) in Cambodia (Hinton & Lewis-­Fernandez,
2010). Although not equivalent to PTSD symptoms, these manifestations
could indicate the presence of traumatization that needs to be explored in a
culture- ­sensitive assessment.
Health care professionals in some countries have developed concepts
of supra-­individual (collective, community, or societal) trauma aftereffects
that are of relevance for mental health care interventions (Bhugra & Becker,
2005). In collectivistic or sociocentric cultures, the impact of traumatic events
can be far-­reaching through changes in family and community relationships,
institutions, practices, and social resources, resulting in consequences such
as loss of communality (Beiser, Wiwa, & Adebajo, 2010; Betancourt et al.,
2012; Kirmayer, Kienzler, Afana, & Pedersen, 2010) and cultural bereave-
ment (Bhugra & Becker, 2005; Eisenbruch, 1991; Somasundaram, 2007).
Diagnosis/Assessment/Screening: Adults 59

Such supra-­individual effects can manifest in a variety of forms, including

collective distrust; loss of motivation; loss of beliefs, values, and norms;
learned helplessness; antisocial behavior; substance abuse; gender-­ based
violence; child abuse; and suicidality (Abramowitz, 2005; Somasundaram,
2007).
Some cross-­ cultural studies indicate that an extended definition of
PTSD with a broader range of symptoms may be a better way to delineate
trauma-­related disorder (de Jong, Komproe, Spinazzola, van der Kolk, & van
Ommeren, 2005; Morina & Ford, 2008). One reason is the undeniable fact
that torture, genocide, and severe adversity, as well as intergenerational and
historical trauma, are common in some regions or countries of the world
(Evans-­Campbell, 2008; Gone, 2013; Hinton & Lewis-­Fernandez, 2011).
Given that CPTSD is a new disorder, studies assessing DSO symptoms
that might vary across cultures have yet to be conducted. Some of the symp-
toms and problems already identified in the cited studies of PTSD may
fall into the CPTSD profile. For example, affect dysregulation might be
expressed in somatic symptoms such as perumuchu (deep sighing in Tamil
culture) or the bodily weakness associated with Dhat syndrome (see Huma-
yun & Somasundaram, 2018). In more collective societies, a changed sense
of identity and interpersonal relationships may be experienced through loss
of communality, such as the outcast status of Yazidi women who were sub-
jected to sexual slavery (Hoffman et al., 2018; Ibrahim, Ertl, Catani, Ismail,
& Neuner, 2018) or cultural bereavement among those who have experi-
enced violent conflict (Somasundaram, 2007).

Screening for DSM‑5 PTSD and ICD‑11 PTSD/CPTSD

Screening for PTSD has normally been conducted by asking people to rate
a number of symptoms, with a cutoff score denoting that the diagnosis is
probably present. It is perfectly possible to create screening instruments that
take into account many other types of information, but these tend to be only
useful for specific trauma populations, such as adults admitted to the hospi-
tal following injury (O’Donnell et al., 2008). The performance of screening
instruments is usually assessed in terms of their sensitivity, the likelihood
that a person with the diagnosis will score above the cutoff, and their speci-
ficity, the likelihood that a person without the diagnosis will score below the
cutoff. Cutoff scores usually try to achieve an optimal balance of sensitivity
and specificity, while recognizing that scores can be legitimately increased
or decreased in specific contexts. For example, scores may be lowered if sen-
sitivity is the most important criterion.
Screening is sometimes conducted with instruments that assess each
PTSD symptom individually, such as the PTSD Checklist for DSM-5 (PCL-5;
Blevins, Weathers, Davis, Witte, & Domino, 2015), or include larger numbers
of items, such as the Impact of Event Scale–­Revised (IES-R; Weiss, 2007).
60 Introduction and Background

However, because DSM-­defined PTSD has a large number of symptoms, such

a screening process is not necessarily efficient. Shorter instruments might
be able to estimate the likely presence of PTSD with considerable savings
in time and cost. Studies do indeed indicate that those with between four
and ten items, simpler response scales, and simpler scoring methods often
perform as well as, if not better than, longer and more complex instruments
(Brewin, 2005; Freedy et al., 2010; Mouthaan, Sijbrandij, Reitsma, Gersons,
& Olff, 2014). In contrast, a single screening item (“Were you recently both-
ered by a past experience that caused you to believe you would be injured
or killed . . . not bothered, bothered a little, or bothered a lot?”) performed
more poorly (Gore, Engel, Freed, Liu, & Armstrong, 2008).

Screening Instruments
Among the most commonly used short screeners have been the Primary
Care PTSD Screen (PC-PTSD; Prins et al., 2003) and the Trauma Screening
Questionnaire (TSQ; Brewin et al., 2002), both answered with a simple yes/
no response scale. The PC-PTSD includes four items covering nightmares
and intrusive thoughts, active avoidance of thoughts or situations, hyper-
vigilance/startle, and numbness/detachment from people and activities. A
score of 3 or above generally reflects the best screening threshold. The TSQ
has 10 items corresponding to the reexperiencing and hyperarousal ques-
tions from the PTSD Symptom Scale (PSS; Foa, Riggs, Dancu, & Rothbaum,
1993). A score of 6 or above generally reflects the best screening threshold.
Another widely used brief screener is the SPAN self-­report (derived from the
Davidson Trauma Scale; Davidson et al., 1997), which has four items assess-
ing startle, physiological arousal on reminders, anger, and numbness, each
answered on a 5-point severity scale (Meltzer-­Brody, Churchill, & Davidson,
1999). Recently, briefer versions of the PCL-5 containing only four or eight
items have been investigated (Price, Szafranski, van Stolk-Cooke, & Gros,
2016). There has also been interest in using brief screeners within more spe-
cific populations where a high prevalence of PTSD is known to exist. Studies
have confirmed the value of the TSQ in samples with severe mental illness
(de Bont et al., 2015) and of the PC-PTSD in samples with substance use dis-
orders (van Dam, Ehring, Vedel, & Emmelkamp, 2010).
The performance of brief screeners will not necessarily be affected by
changes to diagnostic criteria, such as the three additional symptoms and
one additional symptom cluster introduced in DSM-5 (American Psychiatric
Association, 2013). However, a new version of the PC-PTSD, the PC-PTSD-5
(Prins et al., 2016), has been developed to better assess DSM-5 PTSD. The
authors added one item on guilt or blame and found that the most sensitive
threshold score was 3, whereas optimal efficiency was obtained at 4 and
optimal specificity at 5.
ICD-11, in contrast, has introduced a distinction between PTSD and
complex PTSD, the former being based on only six symptoms and the latter
Diagnosis/Assessment/Screening: Adults 61

on the six PTSD symptoms plus a further six assessing aspects of disturbances
in self-­organization (Brewin et al., 2017). Diagnostic instruments such as
the ITQ (Cloitre et al., 2018) additionally assess functional impairment and
are able to determine an ICD-11 diagnosis while remaining relatively brief.
Six items from the IES-R can also be used to approximate ICD-11 PTSD
(Hyland, Brewin, & Maercker, 2017). Alternative instruments for assessing
complex PTSD, such as the Complex Trauma Inventory (CTI; Litvin, Kamin-
ski, & Riggs, 2017) and the German-­language Screening for Complex PTSD
(SkPTBS; Dorr, Sack, & Bengel, 2018), approximate the final ICD-11 for-
mulation and are likely to become useful additional screening instruments.

General Issues
Psychometric studies on the performance of screening instruments are rela-
tively uncommon, with cutoff scores not always independently validated. It is
nevertheless clear that their performance is likely to vary depending on the
setting and the population sampled (Dow, Kenardy, Le Brocque, & Long,
2012; McDonald & Calhoun, 2010). Translation into other languages may
result in slightly different cutoff scores being optimal, even if overall perfor-
mance remains good (Dekkers, Olff, & Näring, 2010).
These considerations need to be borne in mind when screening is
implemented on a larger scale. For example, screening has recently begun
to be regularly employed after major incidents in conjunction with active
outreach to overcome the known failure of traditional mental health path-
ways to detect and provide evidence-­based treatment to those affected. A
positive screen is typically followed by a more detailed clinical assessment to
determine whether treatment is required. This strategy has been employed
successfully after incidents such as the 2005 terrorist bombings in London
(Brewin, Fuchkan, Huntley, Robertson, et al., 2010) and the 2009 plane
crash at Amsterdam Airport (Gouweloos-­Trines et al., 2019).
A more detailed investigation of screening performance was con-
ducted using the TSQ during the London bombings mental health program
(Brewin, Fuchkan, Huntley, & Scragg, 2010). It showed, consistent with evi-
dence supporting temporarily increased levels of general stress after terror-
ist incidents, that the specificity of the TSQ was low directly after the bomb-
ings but increased steadily over the two years following them. There was
also evidence that members of ethnic minority groups tended to score more
highly overall, reducing the specificity of the TSQ when the original cutoff
score was used. Other studies have found that the TSQ had greater sensitiv-
ity than specificity shortly after major incidents, indicating that in these situ-
ations use of the TSQ maximizes the chance of identifying affected persons
at the expense of some unnecessary clinical assessments (Gouweloos-­Trines
et al., 2019). It is likely that the performance of all screening instruments
varies according to situational and personal factors, but this subject is rarely
studied and should be a priority for future research.
62 Introduction and Background

Screening Summary
Relatively brief screening measures appear to be as effective as longer ques-
tionnaires. Their main value is detecting the presence of probable PTSD in
large samples for whom more detailed assessment is not feasible, such as
patients suffering from other disorders where a history of trauma is com-
mon or people being exposed to a major traumatic incident such as an
earthquake, transportation accident, or terrorist attack. Research to date
has suggested that existing measures are suitable for these purposes and
can yield adequate sensitivity and specificity. Nevertheless, data on their
performance in different settings and with different populations are insuf-
ficient, and considerable further research is needed to establish optimal
screening procedures.

Concluding Remarks

The introduction of DSM-5 and ICD-11 highlights a significant divergence

in the approach to diagnosis of PTSD by the principal classification systems,
and the addition of a new diagnosis, CPTSD, to ICD-11. Early underpin-
nings of CPTSD can be seen in the disorders of extreme stress not other-
wise specified (DESNOS) concept, but this is the first time that a formal
parallel diagnosis to PTSD has been introduced. The divergence raises a
number of issues; some people will meet diagnostic criteria according to
one system but not the other, risking interchangeable use of the diagnos-
tic systems and the potential for confusion—­for example, how should we
define PTSD to someone affected by a traumatic event(s)? The divergence
also provides research opportunities to assess and compare the utility of
the new systems, and to develop more personalized treatments designed
to treat specific constellations of symptoms; very different approaches may
be required to treat CPTSD, ICD-11 PTSD, and DSM-5 PTSD. Whatever we
think about the divergence, it is here to stay, at least until the next DSM and
ICD revisions, and it is important that we embrace the changes and use them
to facilitate better approaches to the detection, assessment, prevention, and
management of PTSD and CPTSD.

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C H A P TE R 5

Screening, Assessment, and Diagnosis

in Children and Adolescents
Lucy Berliner, Richard Meiser‑Stedman, and Andrea Danese

Trauma Exposure and Impact

Children are exposed to potentially traumatic events (PTEs) at high rates.

Population-­based studies directly interviewing children and young adults
about PTE show that a majority of children throughout the world experi-
ence threat-­related events, including child abuse, rape, family and commu-
nity violence, natural disasters, serious accidents, the sudden or violent loss
of loved one, and war (Finkelhor, Turner, Shattuck, & Hamby, 2015; Lewis
et al., 2019; Saunders & Adams, 2014; Sumner et al., 2015). Rates are even
higher in clinical populations that include children in psychiatric inpatient
settings, child welfare, and juvenile justice (Dierkhising et al., 2013; Havens
et al., 2012; Salazar, Keller, Gowen, & Courtney, 2013). Not all children who
experience a PTE will develop posttraumatic stress disorder (PTSD) or clini-
cally significant posttraumatic stress symptoms. In trauma-­exposed samples
of youth, Alisic and colleagues (2014) found that, on average, 16% met diag-
nostic criteria for PTSD; higher rates were found for girls and for interper-
sonal trauma. About a third of girls with interpersonal trauma developed
PTSD. Trauma-­exposed young people are not only at risk for PTSD but can
also develop the full range of emotional and behavioral disorders (Lewis et
al., 2019).

Predisposing Factors
Since only a fraction of trauma-­exposed young people develop PTSD, it is
important to characterize which factors may increase risk for PTSD in young
people who are exposed. Research indicates several potential characteristics

69
70 Introduction and Background

of the trauma, the child, and the family that could increase risk of PTSD
in trauma-­exposed young people. For example, interpersonal traumas (e.g.,
child physical or sexual abuse) are associated with greater PTSD risk com-
pared to public events (disasters) and single-­event traumas (e.g., road traf-
fic crashes; Alisic et al., 2014; Cisler et al., 2012). Prior victimization, pre-
vious psychiatric history, family psychopathology, and social disadvantage
may increase risk of PTSD. Trickey, Siddaway, Meiser-­Stedman, Serpell, and
Field (2012) found that factors related to the subjective experience during
the event (e.g., fear, life threat) and posttrauma responses (e.g., low social
support, family dysfunction, avoidance) had more influence than pretrauma
risk factors and severity of the event. All these factors have been shown to
identify groups of trauma-­exposed young people at greater risk of PTSD.
However, only an initial understanding exists of their clinical utility in esti-
mating individualized risk prediction in any particular young person (Lewis
et al., 2019).
At this time, identification of children with clinical need due to trauma
exposure and trauma impact is the most critical task. There are effective
treatments for PTSD and trauma impact in children (Gilles, Taylor, Gray,
O’Brien, & D’Abrew, 2013; Gutermann et al., 2016; Jensen, Holt, Mørup
Ormhaug, Fjermestad, & Wentzel-­Larsen, 2018; Morina, Koerssen, & Pollet,
2016), but without identification, the children in need will not receive the
benefit of these therapies. Trauma exposure and trauma impact assessment
are the primary strategies for increasing identification of trauma-­exposed
and affected children in need of trauma-­specific mental health services and
for ensuring they get access to effective care.
This chapter will review trauma screening and trauma impact assess-
ment procedures. In some cases, trauma screening will already have been
done in another often nonclinical setting (e.g., school, child welfare, primary
care, child advocacy centers, juvenile justice). We focus primarily on screen-
ing and assessment of children and families in the clinical context. In some
cases, these activities will take place in specialty clinics for trauma. However,
most children with mental health needs receive behavioral health care in
nonspecialty settings that provide clinical services for the full range of child-
hood disorders (e.g., Medicaid Behavioral Health Services in the United
States; Child and Adolescent Mental Health Services in the United King-
dom and Australia). There are also some circumstances where a population
approach to trauma screening may be indicated, and it will take place in a
nonclinical setting. For example, children in a school where there has been
a school shooting or a community that has suffered a major natural disaster
may be best served by screening in a more natural setting.
For children affected by trauma, we are not just concerned with making
a PTSD diagnosis. We want to ensure that all children exposed to potentially
traumatic events are identified and, once identified, are assessed to deter-
mine if they are safe or might be experiencing ongoing risk, even before they
are assessed for PTSD and other behavioral health need. Our primary focus
Screening/Assessment/Diagnosis: Children and Adolescents 71

in this chapter will be PTSD, but we will consider other common disorders
such as depression that occurs even more frequently in exposed children
than PTSD. We will follow the flow that typically would occur, especially
in nonspecialty settings where most affected children will receive care. The
chapter will proceed from screening for trauma exposure to brief screening
for trauma impact, diagnosis-­based self-­report measures, structured diag-
nostic interviews, and finally diagnosis including addressing comorbidities.
The goal is to ensure that all affected children are identified and receive
appropriate care.
The chapter will cover both comprehensive trauma screening and
assessment procedures as might be the standard of care in specialty clin-
ics, as well as the more basic trauma screening and assessment that can be
carried out in primary care and general child mental health programs. The
emphasis will be on procedures and measures that can be implemented at
low or no cost.

Routine Screening for Trauma Exposure

and Impact
Screening as an Opportunity
Screening for exposure to trauma is the first and necessary step for identify-
ing children at risk for ongoing harm and at risk for behavioral health con-
cerns because children do not typically volunteer their trauma experiences.
Exposure to potentially traumatic events by itself or in combination with
other adversities substantially increases risk for psychopathology (Lewis et
al., 2019; McLaughlin et al., 2012). McLaughlin and colleagues (2012) found
that exposure to trauma and other adversities accounted for a substantial
portion of childhood (45%) and adolescent (32%) onset of all psychiatric
disorders.
Trauma exposure screening and/or brief trauma impact screening can
be undertaken in primary care or nonspecialty behavioral health settings.
This will be the best method of identifying children with PTSD. Children,
even those receiving behavioral health services, frequently do not report
their trauma experiences or are not seeking care for a trauma-­specific disor-
der such as PTSD. Many children exposed to trauma and other adversities
and suffering from PTSD are likely receiving care in nonspecialty behav-
ioral health settings. In the absence of routine trauma exposure and trauma
impact screening, their trauma histories may never be uncovered; they may
remain in danger or be misdiagnosed.
However, routine screening in health settings, especially for expo-
sure to adverse events and behavioral health conditions, must be under-
taken thoughtfully. Recommendations to screen in primary care settings
have become more common for adverse experiences (e.g., DV, ACEs) or
behavioral health conditions such as depression in adults and adolescents
72 Introduction and Background

(www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummary­Final/
depression-­in-­children-­and-­adolescents-­screening). However, controversies
remain about the value of routine screening. For example, screening for
exposure to domestic violence has not proven helpful for patients (e.g.,
McLennan & MacMillan, 2018). Finkelhor (2018) raised the issue of caution
for screening for childhood adversities as recommended by the American
Academy of Pediatrics (Garner et al., 2012). Screening is not always helpful
and may even be harmful (e.g., create negative expectancies, cause worry,
lead to unnecessary services). Therefore, if trauma screening is to be done,
procedures to review results and facilitate access to trauma therapy must be
in place for children who screen in.
The purpose of behavioral health screening is to help patients with
clinical need. Unfortunately, even when clinical need is identified, most chil-
dren with mental health need do not receive mental health services (Kovess-­
Masfety et al., 2017; Lewis et al., 2019; Merikangas et al., 2011; Sawyer et al.,
2018; Simon, Pastor, Reuben, Huang, & Goldstrom, 2015). Children with the
internalizing disorders that are most associated with trauma-­specific impact
such as PTSD, depression, and anxiety are less likely than youth with disrup-
tive disorders to be referred or access needed services even when identified.
Therefore, simply identifying children exposed to trauma or with elevated
trauma-­related symptoms is insufficient without a commitment to ensure
that a benefit accrues to the patients. For example, care should be taken to
convey a message that while having a trauma history increases risk for delete-
rious outcomes, not all exposed children develop trauma or other disorders
and effective treatments are available. Providers who screen and identify
children with trauma-­specific or other mental health need must be prepared
to offer services or facilitate access to services.
We contend that administration of trauma exposure and impact mea-
sures and review of the results with the client can be conceptualized as a
therapeutic clinical encounter. First, it gives a message to children that pro-
fessionals are aware trauma exposure occurs, are interested to learn about it
from clients, and can handle hearing about trauma. Second, going over the
results of the screen creates an opportunity for validation (“I’m sorry that
happened to you”), normalization (“you are not alone, traumas are common
in children’s lives”), and psychoeducation regarding impact (“traumas are
threat events that can cause reactions”), and instills hope (“we have a treat-
ment that works for posttraumatic stress”). Screening can also initiate the
core elements of effective trauma treatments, such as exposure and identify-
ing unhelpful thoughts to target in therapy.

Trauma Screening Concerns

There has been significant concern that screening for trauma exposure is
distressing for children. The evidence does not bear that out. Population-­
based studies that screen youth regarding victimization history typically use
Screening/Assessment/Diagnosis: Children and Adolescents 73

lay interviewers. They are able to elicit reports of victimization and trauma
from youth as young as 10 years old without having mental health train-
ing or a therapeutic relationship with the respondent. Several such studies
have directly asked children about distress and find that very few children
report the interviews as even mildly upsetting (Finkelhor, Vanderminden,
Turner, Hamby, & Shattuck 2014; Landolt, Schnyder, Maier, Schoenbucher,
& Mohler-­Kuo, 2013; Zajac, Ruggiero, Smith, Saunders, & Kilpatrick, 2011).
In a clinical context, Skar and colleagues (Skar, Ormhaug, & Jensen, 2019)
incorporated routine trauma exposure and impact screening into an imple-
mentation study of trauma-­focused cognitive-­behavioral therapy (TF-CBT)
in mental health clinics across Norway. To identify children eligible for TF-
CBT, clinics were expected to screen all children. They have assessed thou-
sands of service-­seeking children and youth. Overall, only a small minority
report distress at screening. Talking about trauma does not cause distress
in young people without trauma exposure and only leads to minimal dis-
tress among children with trauma exposure but without PTSD. Children
with PTSD are somewhat more likely to be distressed, but this should be
expected. The distress of disclosure is unlikely to be experienced as more
overwhelming than their everyday experience of living with PTSD; and the
relief at being taken seriously may more than compensate for any short-lived
upset. It is essential to identify children who have been exposed and have
developed PTSD, in order to plan further assessment and treatment.

Potential Screening Impact

Although many children who are exposed to trauma will report their experi-
ences and the impact if given a direct opportunity, it should always be kept
in mind how difficult young people can find acknowledging and talking
about trauma. Even with direct questioning, children may not initially report
trauma as they might fear upsetting parents, being stigmatized, and caus-
ing trouble for themselves or others. They may worry about being believed
and supported. In certain cases of interpersonal violence, especially when
it occurs within the home, revealing information may lead to negative out-
comes such as family separations or breakup. And clinically, children may
want to actively avoid discussing these experiences because it is upsetting to
recall the events or triggers distressing reliving symptoms.
It is also important to bear in mind that young people may not be pre-
pared initially to provide the full details of the trauma they acknowledge dur-
ing screening. Clinicians have an important role to play in facilitating facing
up to and talking about trauma by creating a safe environment and trusting
relationship. Clinicians should reassure young people that it is helpful to
talk about bad experiences and encourage candor, but stress that whatever
level of detail the young person is willing to share initially will be accepted.
Clinicians must consider confidentiality when asking children about
trauma experiences, especially those that may occur within the family, such
74 Introduction and Background

as sexual or physical abuse or domestic violence. In some countries, there

are mandatory child abuse reporting laws that would be triggered if a child
discloses maltreatment. Clinicians should be familiar with the laws in their
country or jurisdiction as well as the procedures that must be followed and
what clients can anticipate in any child protection systems. Clinicians can
actively support children in sharing their traumas with their parents or in
contacting authorities to mitigate the potential negative fallout of a report
of maltreatment.
In addition, other legal considerations can come into play. Clinicians
should avoid asking many leading questions, especially with younger chil-
dren. Extensive direct questioning can cause children to acquiesce or in
some cases even change aspects of their memories. This could be harmful,
including undermining young peoples’ credibility and disqualifying their
account during legal proceedings. Open-ended approaches tend to produce
the most complete and accurate accounts.
It is not clinically necessary to know all the facts; what is clinically impor-
tant is to learn if a trauma has happened and how it has affected the young
people from their perspective. Elicitation-­oriented questioning, acceptance,
nonjudgmental approaches, and encouragement to focus on thoughts and
feelings versus specific facts can reduce the risk of memory error or mis-
statements and be more clinically meaningful.
Overall, research and clinical experience support the idea that the ben-
efits of routine screening in clinical settings outweigh any drawbacks as long
as it is done in a sensitive, clinical way. Routine screening is feasible and does
not induce distress in nonexposed children, and when distress occurs, it is
mostly in the children with clinically significant posttraumatic stress who
are the very children that need to be identified in order to be helped. Thus,
we recommend trauma exposure and impact screening as a standard part
of intake or initial assessment procedures in clinical settings, provided it is
accompanied by supportive, clinically oriented feedback.

Screening and Assessment Questionnaires

and Checklists

Questionnaires and checklists are essential tools for assessing trauma expo-
sure and PTSD in children and young people. For individual assessment,
they offer a brief and time-­efficient way of determining whether a child has
been exposed to trauma and, if exposed, the presence of posttraumatic stress
symptoms and whether symptoms are clinically significant. Administration
of questionnaires does not require a young person to discuss a trauma with
a clinician, possibly reducing distress around assessment.
Screening measures also allow for population-­ level approaches with
groups of trauma-­exposed young people for whom individual assessment
would not be feasible. They can provide an approximate assessment of PTSD
Screening/Assessment/Diagnosis: Children and Adolescents 75

symptom severity. For cases with only mild symptoms, this then gives clini-
cians a convenient way of reassuring parents and caregivers that although
some symptoms may be present, they are of a level that would not normally
warrant treatment.
Standard measures provide clinicians with an important tool for index-
ing trauma exposure, which may be particularly important when a child
or young person is only just beginning to disclose a long and complicated
history of trauma or when a child or young person finds the process of
disclosure very difficult. There are a wide range of well-­validated measures
available with subtly different structures and purposes, facilitating clinicians
across settings.
Of course, questionnaires and checklists also have their limitations that
clinicians need to keep in mind. Reading comprehension is critical to assess;
it may be necessary to read the checklists to younger children or explicitly
encourage them to ask questions if they do not understand. Questionnaires
can be scored or interpreted incorrectly. Questionnaire administration may
allow fewer opportunities for children and young persons to ask questions
or clarify the meaning of some items. To our knowledge, no measure has
complete accuracy, and cutoffs are produced based on the responses from
certain groups in particular contexts.
Completing a questionnaire can be an upsetting activity for some chil-
dren, and efforts should be made to ensure that appropriate care and sup-
port are available if needed. On occasion, questionnaires may be viewed
with some distrust, although with proper explanation, we find their value
can be understood by children. Care must also be taken when consider-
ing the environment for completing questionnaires; while the clinic gener-
ally offers a suitable setting for this activity, a school classroom may require
additional measures to ensure privacy and support. Though comparatively
“cheap,” the interpretation and processing of questionnaires in situations
where a large number of youth are completing them at the same time still
require considerable diligence and attentiveness.
Given these concerns, it is important to recognize that questionnaires,
while remaining an essential tool, are an aid for good clinical work rather
than authoritative or beyond reproach. It is our experience that in the clinic,
questionnaires and checklists are frequently useful as a prompt for further,
more detailed discussion of trauma histories and particular symptoms.

Trauma Exposure Screening

One important consideration with trauma screening and assessment check-
lists is the distinction between exposure and trauma symptoms. Exposure
screeners simply ask the young person whether or not an event has hap-
pened. They are not scored and conclusions cannot be drawn about the
accuracy of the response. Sometimes children are confused, conflate events,
or omit mention of actual traumas. Exposure screening per se should be
76 Introduction and Background

considered the explicit clinical invitation to acknowledge trauma experi-

ences, not the definitive means of establishing a complete trauma history.
Knowing about trauma exposure is necessary before assessing for post-
traumatic stress symptoms since there must be a traumatic stressor that is
tied to the symptoms. For diagnostic purposes, the symptoms have to have
developed or been exacerbated following the event. Sometimes the trauma
is known (e.g., emergency room visit or hospitalization for injury, exposure
to public disaster) and only impact screening is necessary. For example, the
Child Stress Disorders Checklist Short Form (CSDC) is designed for injured
children and includes only four items (e.g., “child gets very upset if reminded
of the trauma”; Bosquet Enlow, Kassam-­Adams, & Saxe, 2010). In cases where
the trauma is not already known, most trauma exposure screens comprise the
first section of screening measures for trauma impact. Typically, these check-
lists include both a trauma screen and an assessment of PTSD symptoms. There
are very brief psychometrically sound exposure and impact screeners in the
public domain, such as the Child Trauma Screen (CTS; e.g., Lang & Connell,
2017). The trauma exposure screen consists of four items (e.g., “Have you ever
seen people pushing, hitting, and throwing things at each other, or stabbing,
shooting, or trying to hurt each other?”). Several more in-depth measures
include both a trauma screen and assessment of PTSD symptoms consistent
with DSM-5 (Child and Adolescent Trauma Screen [CATS]: Sachser, Berliner,
et al., 2017; Child PTSD Symptom Scale for DSM-5 [CPSS-5]: Foa, Asnaani,
Zang, Capaldi, & Yeh, 2018; UCLA PTSD Reaction Index [UCLA PTSD-RI]:
Kaplow et al., 2020). The trauma exposure screen sections contain 14 pos-
sible traumas and an option for another as perceived by the respondent (child
or parent). The Trauma Event Screening Instrument for Children (TESI-C;
Ribbe, 1996) only assesses the trauma events but in great detail.

Assessing Trauma Impact

If young people report trauma exposure or are known to have been exposed
to trauma, it is important to assess for the presence of trauma-­related psy-
chopathology. Although most children show emotional and behavioral
symptoms in the aftermath of a traumatic experience, these symptoms are
often transient, and most trauma-­exposed young people do not develop clin-
ically significant, persistent psychopathology due to the event. Therefore,
screening for trauma-­related psychopathology is often only undertaken a
few weeks after trauma.
Screening in generic child and adolescent mental health settings can be
brief, for example, with the support of a short, validated screening measure
for PTSD (e.g., Child Revised Impact of Event Scale [CRIES]). When pos-
sible, the screening should also include brief assessment of other types of
psychopathology or overall psychopathology, as psychiatric disorders with a
higher base rate in the general population (e.g., depression) also have higher
prevalence in trauma-­exposed young people.
Screening/Assessment/Diagnosis: Children and Adolescents 77

When trauma-­exposed young people screen positive for PTSD or clini-

cally distressing posttraumatic stress, more detailed assessment of symptoms
is required. The intensity and duration of this assessment will necessarily
vary based on the setting. In general clinical settings, PTSD assessment may
be undertaken through more detailed trauma-­specific questionnaires (e.g.,
CATS, CPSS, UCLA PTSD-RI) and/or unstructured interviews focusing on
cardinal symptom dimensions (e.g., reexperiencing, avoidance, arousal).
Functional impairment should also be routinely assessed. In specialist set-
tings, PTSD assessment is typically more in-depth and includes structured
or semistructured interviews and may include direct observation of behavior
in nonclinical settings. Specialty clinics also often use repeated assessments
of posttraumatic stress to provide a way of monitoring session-­by-­session
recovery or, occasionally, deterioration. Regardless of setting, it is essential
that children and young people be screened and assessed directly and on
their own. Questionnaires should be completed by children as soon as they
are developmentally able (e.g., around 7 years).
Parents or other caregivers should be actively involved in the assess-
ment. They are critical for gaining a comprehensive impression because they
know more about their children and see them under many more circum-
stances. They can contribute important collateral information on the young
person’s clinical presentation, in addition to essential historical details (e.g.,
pretrauma functioning, timeline of symptoms’ presentation, psychiatric his-
tory, developmental history) and information on family functioning (e.g.,
family composition and functioning, family history of psychopathology,
family reaction and adaptation to the trauma).
However, it is important to bear in mind that parents may under- or over-
report PTSD symptoms and other psychiatric symptoms after trauma. On the
one hand, this may be due to the difficulties in detecting internalized symp-
toms, framing clinical-­level symptoms as normal reactions to difficult experi-
ences. Or, parents may withhold information on symptoms they have observed
because of fears, worries, stigma, or in some cases the minimization of trauma
impact on their child. On the other hand, some parents may overattribute
symptoms and behaviors to trauma (e.g., parents with their own trauma his-
tory; parents seeking to externalize the cause of their child’s difficulties).

Checklists and Questionnaires

Quite a number of questionnaires and subscales are available for trauma
exposure screening and/or assessment of trauma-­related impact. Some are
very brief screeners, whereas others produce a probable PTSD diagnosis. We
have opted to consider two broad classes of measures separately: question-
naires and checklists that are not specific to a particular diagnostic model,
and diagnosis-­specific scales. We also consider scales that may be useful for
informing the psychological formulation of an individual child or young
person’s posttraumatic stress response.
78 Introduction and Background

Non‑Diagnosis‑Specific Questionnaires and Checklists

We outline several measures of this type in Table 5.1. We list those measures
that are most widely used and have the most robust psychometric validation.
This is not a systematic review of all available measures, and although we
have sought to provide the most up-to-date information about each one, we
would encourage clinicians to stay alert to the publication of further data on
each scale. We also make the following observations about these measures.
First, the breadth of available measures in this group should ensure that cli-
nicians can identify an instrument specific to the needs of their own client
group and setting or context. Second, the strength of using one of the fol-
lowing measures is that all are unlikely to be made redundant with further
diagnostic innovations—­t hey are likely to withstand further iterations of the
PTSD diagnosis (e.g., DSM-6, ICD-12). Third, this list is specific to measures
based on the responses of children or young persons or responses from their
parents or caregivers. Other screening tools that also incorporate demo-
graphic, medical, or other trauma-­related information are available (e.g., the
Screening Tool for Early Predictors of PTSD [STEPP]).
The Child Trauma Screen (CTS), the Child Stress Disorders Check-
list–­SS (CSDC), and the Child Trauma Screening Questionnaire (CTSQ)
are brief tools for screening children and young people exposed to trauma;
the Young Child PTSD Screen performs the same function but specifically
for young children. Each measure provides a clear cutoff for identifying chil-
dren and young people at high risk of having PTSD, and therefore deserving
of further attention. The CTS also includes a trauma exposure screen.
The Child Revised Impact of Event Scale (CRIES) may function as both a
screening instrument (particularly in its brief eight-item format) and a sever-
ity/intensity measure. A particular strength of the CRIES is its availability
in numerous languages (see www.childrenandwar.org/measures). The Pediatric
Emotional Distress Scale (PEDS) is aimed at preschool and younger chil-
dren, addressing many “core” PTSD symptoms and symptoms considered
specific to this age group (e.g., clinginess, loss of developmentally appropri-
ate skills, bedwetting).

Diagnosis‑Specific Questionnaires
We list diagnosis-­specific instruments for children and young people in Table
5.2. Several options exist for questionnaires that address PTSD as defined
by DSM-5, while the DSM-IV acute stress disorder diagnosis is addressed by
the Acute Stress Checklist for Children (ASC-Kids; Kassam-­Adams, 2006).
To our knowledge, there are no published measures for ICD-10 or ICD-11
PTSD, or the newly introduced ICD-11 complex PTSD (CPTSD) diagnosis.
Where these constructs have been investigated, researchers have used the
items from DSM-5-focused measures; given the subtle differences in wording
between DSM and ICD PTSD symptoms, this approach may be problematic.
 Screening/Assessment/Diagnosis: Children and Adolescents 79

TABLE 5.1. Checklists and Self-Report Questionnaire Measures, Not Diagnosis-Based

psychometrics?

Free to use?
Respondent

Age range

Published
(years)

Items
Measure Reference Type Cutoffs?

Child Revised Dyregrov & CYP Intensity/ 17+ for 8 8–18 8 Yes Yes
Impact of Events Yule (1995) severity item; 30+ or
Scale (CRIES) for 13 item 13

Child Stress Saxe et al. CG/ Screening No 5–17 36 Yes Yes

Disorders Checklist (2003) Par
ASD/PTSD
(CSDC)

Child Stress Bosquet CG/ Screening No 6–18 4 Yes Yes

Disorders Enlow, Par
Checklist—Short Kassam-
Form (CSDC-SF) Adams, &
Saxe (2010)

Child Trauma Lang & CG/ Screening CG/Par 3–18 10 Yes Yes
Screen (CTS) Connell Par, 8+, CYP
(2017) CYP 6+

Pediatric Saylor, CG/ Intensity/ No 2–10 21 Yes Yes

Emotional Distress Swenson, Par severity
Scale (PEDS) Stokes
Reynolds, &
Taylor (1999)

Trauma Symptom Briere (1996) CYP Intensity/ Yes 8–16 54 Yes No

Checklist for severity (T-scores)
Children (TSCC)

Trauma Symptom Briere (2005) CG/ Intensity/ Yes 3–12 90 Yes No

Checklist for Young Par severity (T-scores)
Children (TSCYC)

Young Child PTSD Scheeringa & CG/ Screening Yes 3–6 6 No Yes
Screen (YCPS) Haslett (2010) Par

Child Trauma Kenardy, CYP Screening Yes (5+) 7–16 10 Yes Yes
Screening Spence, &
Questionnaire Macleod
(CTSQ) (2006)

Note. CYP, child or young person; CG/Par, caregiver or parent.

 80 Introduction and Background

TABLE 5.2. Self-Report Questionnaire Measures, Diagnosis-Based

psychometrics?

Free to use?
Respondent

Published
Age
range
Measure Reference Cutoffs? (years) Items

Acute Stress Kassam- CYP Nov 8–17 29 Yes Yes

Checklist for Adams (2006)
Children (ASC-Kids)

Child and Sachser, CG/ Yes (21+) 3–17 20 (7–17 Yes Yes
Adolescent Trauma Berliner, et al. Par; years); 16
Screen (CATS) (2017) CYP (3–6 years)

Child PTSD Foa, Asnaani, CYP Yes (31+) 8–18 20 PTSD Yes Yes
Symptom Scale for Zang, Capaldi, symptoms
DSM-5 (CPSS-5) & Yeh (2018)

UCLA PTSD Kaplow et al. CG/ Yes (38+, 7–18 31 Yes No

Reaction Index (2020) Par; DSM-IV (DSM-IV
(UCLA PTSD-RI) CYP version) version)
Note: CYP, child or young person; CG/Par, caregiver or parent.

Three measures—­CATS, CPSS-5, and UCLA PTSD-RI—offer a compre-

hensive assessment of DSM-5 PTSD symptomatology. They include the trau-
matic stressor screen; the four symptom clusters of intrusion, avoidance,
negative alteration in cognitions and mood, and alterations in arousal and
reactivity; and impairment. It is also important to note that the DSM-IV
forms of the CPSS and UCLA PTSD-RI have been widely used, including
in clinical trials, and that such data may still be useful in certain contexts.
With the advent of ICD-11 and its new conceptualizations and defini-
tions for PTSD and CPTSD, new measures are currently in development.
With some adjustments to the intrusion symptoms to capture “nowness” in
reexperiencing, it is possible to crosswalk from DSM-5 to ICD-11 PTSD. The
“negative alternations in cognitions and mood” symptom cluster included
in the DSM-5 PTSD criteria may to some extent address the “complexity”
that is encapsulated within the CPTSD diagnosis. Currently, one study finds
support for the existence of CPTSD in children using a DSM-5 measure
and selected items from other measures used in a TF-CBT randomized trial
(Sachser, Keller, & Goldbeck, 2017). However, at this time, there is no alter-
native treatment for young people with CPTSD, and some evidence exists
that CPTSD can benefit from standard evidence-­based CBTs for trauma.
Treatment for PTSD and CPTSD in children and adolescents is expanded on
by Jensen, Cohen, Jaycox, and Rosner (Chapter 21, this volume).
Screening/Assessment/Diagnosis: Children and Adolescents 81

Structured and Semistructured Interview Assessments for PTSD

in Children and Young People
There are instances where a structured or semistructured interview assess-
ment for PTSD is essential, such as when a formal diagnostic process is
required to access health care; to establish unequivocally that PTSD is pres-
ent and its importance relative to other needs; for medicolegal assessment;
and where self-­report measures are inappropriate (e.g., if a child or young
person lacks the appropriate literacy skills). A structured assessment has
several advantages over self-­report measures. Although more intrusive and
time-­consuming, an interview potentially allows for a far more thorough
understanding of a child or young person’s symptoms and how they occur in
their familial and developmental context, their onset and impact. Clinically,
a well-­conducted, empathic comprehensive interview assessment may help to
build a therapeutic relationship and establish a solid platform for psycholog-
ical therapy. Of course, a clinician may simply use a given diagnostic frame-
work (e.g., DSM-5, ICD-11) to direct his or her clinical assessment. How-
ever, a structured interview assessment typically supports the interviewer
by providing follow-­up questions and points of clarification, and support
for children and young people in framing their responses (e.g., by offering
several options for time period or frequency). A structured interview may
also be very useful for non-­mental health professionals or paraprofessionals,
for example, more junior staff who conduct initial assessment, or research
assistants working in the context of a clinical trial.
Several structured interview assessments are available for assessing
PTSD in children and young people (see Table 5.3). As with diagnosis-­
specific questionnaire measures, these were produced to assess DSM-IV or
DSM-5 PTSD. Although several PTSD-­specific interviews are available, the
Anxiety Disorders Interview Schedule (ADIS), Kiddie Schedule for Affec-
tive Disorders and Schizophrenia (K-SADS), and Diagnostic Infant and Pre-
school Assessment (DIPA) include PTSD as part of a broader assessment of
different psychiatric diagnoses. These interviews involve some initial probe
or screening questions, with additional questions then asked to confirm the
presence of a particular diagnosis or class of diagnoses. At least two inter-
view assessments are interview-­formatted versions of other questionnaires
(CPSS5; UCLA RI). (See Table 5.2.)

Other Measures for Use with Trauma‑Exposed Children

and Adolescents
Assessing trauma-­related appraisals or beliefs is extremely important. They
are considered a key etiological factor in cognitive behavioral models of
PTSD. Multiple recent studies (Hiller et al., 2019; Jensen et al., 2018; McLean,
Yeh, Rosenfield, & Foa, 2015; Pfeiffer, Sachser, de Haan, Tutus, & Goldbeck,
 82 Introduction and Background

2017) have found that trauma-­related cognitions mediate PTSD symptoms

and symptom reduction. Therefore, it is critical to assess cognitions that
may be perpetuating the PTSD symptoms. The Child Post-­Traumatic Cogni-
tions Inventory (CPTCI; Meiser-­Stedman et al., 2009) is validated for older
children and adolescents, and has been translated into multiple languages.
An abbreviated 10-item form of the CPTCI has also been validated and may
support its brief administration in therapy sessions (McKinnon et al., 2016).

TABLE 5.3. Structured Interview Assessments for Children and Young People

psychometrics?
Proposed age
range (years)

Free to use?
Respondent

Diagnostic

Published
system
Interview Reference Type

Clinician- Pynoos et al. CYP DSM-5 PTSD- 7+ Yes Yes

Administered (2015) specific (DSM-IV
PTSD Scale for version)
DSM-5—Child/
Adolescent Version
(CAPS-CA-5)

Child PTSD Foa, Asnaani, CYP DSM-5 PTSD- 8–18 Yes Yes
Symptom Scale for Zang, specific
DSM-5, interview Capaldi, &
(CPSS-5-I) Yeh (2018)

Children’s Saigh (2004) CYP DSM-IV PTSD- 6–18 Yes No

Posttraumatic Stress specific
Disorder Inventory
(CPTSDI)

Anxiety Disorders Silverman CYP, DSM-IV Multi­ 7–16 Yes (for Yes
Interview Schedule & Albano CG/ disorder full
(ADIS-IV): Child (1996) Par schedule)
and Parent
Interview Schedules

Kiddie Schedule for Kaufman et CYP DSM-5 Multi­ 7–17 Yes Yes
Affective Disorders al. (1997) disorder
and Schizophrenia
(K-SADS)

Diagnostic Infant Scheeringa CG/ DSM-IV Multi­ 9 months– Yes Yes

and Preschool & Haslett Par disorder 6 years
Assessment (DIPA) (2010)

Note. CYP, child or young person; CG/Par, caregiver or parent.

Screening/Assessment/Diagnosis: Children and Adolescents 83

With respect to family context and potential maintaining factors

within that system, two measures have recently been proposed: the Parent
Trauma Response Questionnaire (Williamson et al., 2018) and the Thinking
about Recovery Scale (Schilpzand, Conroy, Anderson, & Alisic, 2018). Each
includes items that address multiple behavioral and cognitive processes
(e.g., child vulnerability, permanent psychological harm to the child, over-
protectiveness and avoidance) that are considered maladaptive in the parent
or caregiver whose child has been subjected to trauma. Assessing parental
PTSD and mood may be clinically indicated; we would encourage the use of
any measure endorsed in the adult section of this volume.
For assessing dissociation, the Child Dissociation Checklist (Putnam,
Helmers, & Trickett, 1993) and Adolescent Dissociative Experiences Scale
(Farrington, Smerden, & Faupel, 2001) have been developed; they offer a
wide-­ranging assessment of a child or young’s person experience of such
phenomena, including depersonalization, derealization, and identity con-
fusion. For peritraumatic dissociative experiences, the child version of the
Peritraumatic Dissociative Experiences Questionnaire (PDEQ-C; Bui et al.,
2011) and ASC-Kids are available.

Formulation and Treatment Recommendations

Diagnosis
A diagnosis of PTSD based on the current World Health Organization
definition (ICD-11; World Health Organization, 2018) is made when chil-
dren and young people have core symptoms in the dimensions of reliving
experiences, active avoidance, and physiological hyperreactivity. Criteria
for a diagnosis of PTSD in the fifth edition of the Diagnostic and Statistical
Manual of Mental Disorders (DSM-5; American Psychiatric Association, 2013)
are broader; children and young people have the above core symptoms and
negative alterations in mood and cognition that are trauma-­related. DSM-5
also includes a separate, developmentally appropriate set of symptoms for
diagnosing PTSD in children who are 6 years old or younger.

Differential Diagnosis
Differential diagnosis is important because PTSD is not the most common
condition observed in the aftermath of trauma, as psychiatric disorders
with a higher base rate in the general population (e.g., depression) also have
higher prevalence in trauma-­exposed young people (Lewis et al., 2019).
PTSD symptoms can resemble symptoms of other psychiatric conditions,
which should be carefully investigated. For example, inattention and rest-
lessness seen in trauma-­exposed young people may be explained by pre-
existing ADHD; sleep problems and negative cognitions may be explained
by a depressive episode; avoidance may be explained by anxiety disorders
84 Introduction and Background

(e.g., agoraphobia, social phobia); affect dysregulation may be explained by

substance use or bipolar disorder; and dissociation may be explained by psy-
chosis. These conditions should therefore be directly assessed.

Comorbidity
In addition to identifying alternative explanations for the clinical presenta-
tion, in a diagnostic assessment, it is also important to describe psychiatric
disorders that co-occur with PTSD. A wide range of possible comorbid con-
ditions exist, and those commonly observed in young people with PTSD
include depression, generalized anxiety disorder, conduct disorder, and
alcohol misuse. Comorbidity is the rule rather than the exception in patients
with PTSD (Lewis et al., 2019), and the type of comorbidity may inform
treatment targets and the overall prognosis. In particular, it is helpful to
clarify the timeline for the onset of various symptoms in order to character-
ize pretrauma functioning and to understand if trauma-­focused treatment
might also relieve secondary symptoms (e.g., depressive symptoms).

Precipitating Factors
PTSD is unique in comparison to other types of psychopathology because
the disorder is unambiguously linked to a causal risk factor, namely, the
index trauma. PTSD diagnosis requires endorsement of an index trauma. If
symptoms of PTSD are present in the absence of an established or reported
trauma exposure, the diagnosis cannot be given. Instead, clinicians should
consider the differential diagnoses discussed previously. This is especially
true because many of the nonspecific symptoms in DMS-5 PTSD could result
from other disorders. Exploring the specific symptoms the youth endorsed
in depth, especially the core PTSD symptoms of intrusion and avoidance,
can clarify if there is an eligible stressor that accounts for them (e.g., what
are the upsetting thoughts or memories that are popping into your head?”).
If the youth is reporting distress, he or she should receive care, but it would
not be appropriate to deliver a trauma-­focused therapy without an identified
stressor and clinically significant posttraumatic stress. During treatment for
the distress, a reluctant child may later report trauma once clinicians are
able to build a trusting relationship.

Perpetuating Factors
To identify relevant treatment targets, it is important to understand the
mechanisms that maintain PTSD symptoms. Common mechanisms identi-
fied map onto key PTSD symptoms’ dimensions. Avoidance is cardinal in
PTSD. It leads young people to avoid facing up to the trauma or avoid places
or people that remind them of the trauma but are not dangerous. Avoid-
ance prevents desensitization and can interfere with normal development
Screening/Assessment/Diagnosis: Children and Adolescents 85

activities. Another key mechanism is likely untrue or unhelpful negative

cognitions about themselves, such as guilt, shame, and helplessness. Family
factors can also be important as parents may accommodate the young per-
son’s avoidance strategies in an attempt to reduce distress and may at times
contribute to establishing or perpetuating negative cognitions.

Risk and Opportunity

Trauma exposure and PTSD diagnosis are associated with a substantial
increase in risk for psychiatric disorders, health problems, and impaired
functioning later on. Unlike most other psychiatric disorders, PTSD must
be precipitated by a traumatic stressor. When the stressor is known (e.g., car
crash, earthquake) or is discovered through trauma-­specific screening and
assessment, a unique opportunity is created to intervene early if needed, to
identify high-risk children, and to make sure that children are accurately
diagnosed so they can receive effective treatments.
This volume and the International Society for Traumatic Stress Stud-
ies’ Posttraumatic Stress Disorder Prevention and Treatment Guidelines (www.
istss.org/getattachment/Treating-­Trauma/New-ISTSS-­Prevention-­and-­Treatment-­
Guidelines/ISTSS_PreventionTreatmentGuidelines_FNL.pdf.aspx) resulted in
strong recommendations for several treatments for children and young peo-
ple with posttraumatic stress. The goal of routine screening and assessment
for PTSD in children is to ensure that children and youth with need are
identified and that access to effective treatments is facilitated.

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C H A P TE R 6

ISTSS PTSD Prevention

and Treatment Guidelines
Methodology

Jonathan I. Bisson, Catrin Lewis, and Neil P. Roberts

Tof his chapter outlines the methodology and the subsequent recommenda-
tions for the Posttraumatic Stress Disorder Prevention and Treatment Guidelines
the International Society for Traumatic Stress Studies (ISTSS). Important
issues that should be considered when interpreting the recommendations,
and translating them into practice, are highlighted.

Introduction and Methodology Overview

The recommendations and position papers were developed through a rigor-

ous process that was overseen by the ISTSS Guidelines Committee (listed in
Appendix 6.1). The methodology involved the development of scoping ques-
tions and undertaking systematic reviews to identify randomized controlled
trials (RCTs) that could answer them (Appendix 6.2). Meta-­analyses were
then conducted with usable data from included studies, and the results used
to generate recommendations for prevention and treatment interventions.
A definition of clinical importance and an algorithm for determining the
recommendation level of a given intervention were agreed upon before the
meta-­analyses were undertaken.
Given the limited resources available, it was not possible to commission
new comprehensive systematic reviews in every area. It was, however, pos-
sible to develop a robust and replicable process that systematically gathered

90
ISTSS Guidelines: Methodology 91

and considered the RCT evidence currently available for any intervention
in a standardized manner. A process adapted from approaches taken by the
Australian Centre for Posttraumatic Mental Health (2007; now the Phoenix
Australia–­Centre for Posttraumatic Mental Health), the Cochrane Collabo-
ration (Higgins & Green, 2011), the United Kingdom’s National Institute for
Health and Care Excellence (NICE; 2005), and the World Health Organiza-
tion (WHO; 2013) was used.
The Committee agreed on general scoping questions in a PICO (popu-
lation, intervention, comparator, outcomes) format (e.g., “For adults with
PTSD [posttraumatic stress disorder], do psychological treatments, when
compared to treatment as usual, waiting list, or no treatment, result in a
clinically important reduction of symptoms, improved functioning/quality
of life, presence of disorder, or adverse effects?”) for the prevention and
treatment of PTSD in children, adolescents, and adults. Prior to finalization,
the Committee sought and integrated feedback from the ISTSS membership
around these scoping questions.
High-­quality systematic reviews developed through the Cochrane Col-
laboration, NICE, and WHO were identified that addressed the scoping
questions. RCTs from these reviews were used as the basis of the evidence
to be considered and reevaluated according to the criteria agreed upon for
the ISTSS guidelines. Existing reviews were supplemented with additional
systematic searches for more recent RCTs and by asking experts in the field
and the ISTSS membership to determine if there were any missing studies.
The evidence for each of the scoping questions was summarized and its
quality assessed using the Cochrane Collaboration’s risk of bias rating tool
(Higgins & Green, 2011) to assess for potential methodological concerns
within identified studies. The Cochrane Collaboration’s risk of bias criteria
determine low-, uncertain-, or high-risk ratings for random sequence genera-
tion (selection bias); allocation concealment (selection bias); blinding of par-
ticipants and personnel (performance bias); blinding of outcome assessment
(detection bias); incomplete outcome data (attrition bias); selective report-
ing (reporting bias); and other bias. The GRADE Working Group Grades of
Evidence system (see www.gradeworkinggroup.org) was used to determine the
level of confidence that the estimate of the effect of an intervention is cor-
rect. There are four possible ratings: high quality (further research is very
unlikely to change our confidence in the estimate of effect); moderate qual-
ity (further research is likely to have an important impact on our confidence
in the estimate of effect and may change the estimate); low quality (further
research is very likely to have an important impact on our confidence in the
estimate of effect and is likely to change the estimate); and very low quality
(we are very uncertain about the estimate).
The evidence summaries and quality assessments were then used to
generate draft recommendations using the algorithm described. The draft
recommendations were posted on the ISTSS website during August and Sep-
tember 2018, for a period of consultation by ISTSS members. Feedback was
92 Introduction and Background

incorporated before the recommendations were finalized and approved by

the ISTSS Board in October 2018.

Scoping Questions

Following consultation with the ISTSS membership and reference groups of

practitioners and nonpractitioner consumers, the ISTSS Guidelines Com-
mittee proposed 20 scoping questions that were passed by the ISTSS Board.
Inclusion of separate scoping questions on treatments for complex presen-
tations of PTSD for children, adolescents, and adults was considered. Con-
cerns were raised, however, that due to definitional issues and the virtual
absence of studies specifically designed to answer possible scoping questions
on treatments for complex presentations of PTSD, their inclusion would be
unlikely to provide clear answers.
It was concluded that, rather than systematically reviewing the evi-
dence for the treatment of complex presentations of PTSD, it would likely
be more beneficial to undertake a narrative review of the current situation
with respect to complex PTSD, what it is, and how it should be defined to
enable the development of an evidence base of how best to treat it. Facili-
tated by the publication of the ICD-11 diagnosis of complex PTSD during
the course of the Committee’s operation, position papers (one for children
and adolescents, and one for adults) were developed that consider the cur-
rent issues around complex PTSD and make recommendations to facilitate
further research. The position papers were drafted by members of the ISTSS
Guidelines Committee and in consultation with the rest of the Committee,
the ISTSS Board, and ISTSS membership before being finalized.

Systematic Reviews and Meta‑Analyses

New systematic searches were undertaken by the Cochrane Collaboration

for the period from January 1, 2008, until March 31, 2018, using their com-
prehensive search strategies, to identify RCTs of any intervention designed
to prevent or treat PTSD. Additional RCTs were identified through consul-
tation with experts in the field, including the ISTSS Board and the entire
ISTSS membership.
The new searches identified 5,500 potential new studies. These and
the studies included in existing systematic reviews were assessed against the
inclusion criteria agreed upon for the ISTSS guidelines. The inclusion crite-
ria were designed to focus on reduction in symptoms of PTSD as the primary
outcome and differed slightly for early intervention and treatment studies
(i.e., as opposed to early intervention studies, treatment studies required a
defined severity of PTSD symptoms to be included).
The inclusion criteria for early intervention studies were:
ISTSS Guidelines: Methodology 93

• Any RCT (including cluster and crossover trials) evaluating the effi-
cacy of interventions aimed at preventing, treating, or reducing symp-
toms of PTSD.
• Study participants have been exposed to a traumatic event, as speci-
fied by PTSD diagnostic criteria for DSM-III, DSM-III-R, DSM-IV,
DSM-5, ICD-9, ICD-10, or ICD-11.
• Intervention is not provided pretrauma.
• Intervention begins no later than 3 months after the traumatic event.
• Eligible comparator interventions for psychosocial interventions:
waitlist, treatment as usual, symptom monitoring, repeated assess-
ment, other minimal-­attention control group, or an alternative psy-
chological treatment.
• Eligible comparator interventions for pharmacological interventions:
placebo, other pharmacological or psychosocial intervention.
• The RCT is not solely a dismantling study.
• Study outcomes include a standardized measure of PTSD symptoms
(either clinician-­administered or self-­report).
• No restriction on the basis of severity of PTSD symptoms or the type
of traumatic event.
• Individual, group, and couple interventions.
• No minimum sample size.
• Only studies published in English.
• Unpublished studies eligible.

The inclusion criteria for treatment studies were:

• Any RCT (including cluster and crossover trials) evaluating the effi-
cacy of psychological interventions aimed at reducing symptoms of
PTSD.
• For adults, at least 70% of participants required to be diagnosed with
PTSD according to DSM or ICD criteria by means of a structured
interview or diagnosis by a clinician.
• For children and adolescents, at least 70% diagnosed with partial or
full DSM or ICD PTSD by means of a structured interview or diagno-
sis by a clinician (partial PTSD is defined as at least one symptom per
cluster and presence of impairment), or score above a standard cutoff
of a validated self-­report measure.
• No restrictions on the basis of comorbidity, but PTSD required to be
the primary diagnosis.
• Eligible comparator interventions for psychosocial interventions:
waitlist, treatment as usual, symptom monitoring, repeated assess-
ment, other minimal-­attention control group, or an alternative psy-
chological treatment.
• Eligible comparator interventions for pharmacological interventions:
placebo, other pharmacological or psychosocial intervention.
94 Introduction and Background

• The RCT is not solely a dismantling study.

• Duration of PTSD symptoms required to be 3 months or more.
• No restriction on the basis of severity of PTSD symptoms or the type
of traumatic event.
• Individual, group, and couple interventions.
• No minimum sample size.
• Only studies published in English.
• Unpublished studies eligible.

A total of 361 RCTs fulfilled the criteria for inclusion in the meta-­
analyses undertaken. Studies that fulfilled the inclusion criteria were further
scrutinized to determine if data were available to use in the meta-­analyses,
and to assess risk of bias according to the Cochrane Collaboration criteria.
If sufficient data were not available, requests were made to authors for data
that could be used. A total of 327 (91%) of the included RCTs provided data
that were included in the meta-­analyses. The classification and grouping of
the interventions included are described. The final meta-­analyses and refer-
ence lists of all eligible studies can be found on the ISTSS website (www.
istss.org/getattachment/Treating-­Trauma/New-ISTSS-­Prevention-­and-­Treatment-­
Guidelines/ISTSS_PreventionTreatmentGuidelines_FNL.pdf.aspx).

Definition of Clinical Importance

To generate recommendations from the results of the meta-­analyses, the

following definition of clinical importance was developed and agreed upon:

• PTSD symptom change was the primary outcome measure and other
outcomes (e.g., diagnosis, functioning, other symptom change, toler-
ability) were considered as secondary outcome measures.
• The clinically important definition was based on both magnitude of
change and strength/quality of evidence.
• Informed by previous work in this area (e.g., NICE, 2005) to be rated
clinically important, an intervention delivered 3 or more months
after the traumatic event had to demonstrate an effect size, calculated
as the standardized mean difference (SMD), for continuous outcomes
of >0.8 (<0.65 relative risk for binary outcomes) for wait-list control
comparisons, >0.5 for attention control comparisons (no meaningful
treatment, but same dosage of time/same number of sessions with a
therapist), >0.4 for placebo control comparisons, and >0.2 for active
treatment control comparisons.
• To be rated clinically important, an early intervention started within
3 months of the traumatic event had to demonstrate an effect size for
continuous outcomes of >0.5 for wait-list control comparisons (<0.8
relative risk for binary outcomes).
ISTSS Guidelines: Methodology 95

• If there was only one RCT, an intervention was not normally recom-
mended as clinically important. Noninferiority RCT evidence alone
was not enough to recommend an intervention as clinically impor-
tant.
• Unless there was a GRADE quality of evidence rating of high or mod-
erate, consideration was given to downgrading the strength of recom-
mendation made with respect to clinical importance.
• The primary analysis for a particular question included data from all
included studies. When available, this was clinician rated; when not,
self-­report was included. In addition, an analysis was also considered
of only studies with clinician-­rated data. The combination of these
two analyses was considered along with the GRADE ratings and risk
of bias ratings to determine the strength of recommendation.
• The 95% confidence interval range had to completely exclude the
thresholds for the strongest level of recommendation (e.g., lower
confidence interval of >0.8 for wait-list control comparisons of treat-
ments).

Recommendation Setting

An algorithm was developed to allow the systematic and objective agree-

ment of recommendations after scrutiny of the meta-­analyses pertaining
to individual scoping questions. Consideration was given to magnitude of
change, strength/quality of evidence, and any other important factors (e.g.,
adverse effects).
Five different levels of recommendation were possible. A Strong rec-
ommendation was made for/against interventions with at least reasonable
quality of evidence and the highest certainty of effect. A Standard recom-
mendation was made when there was at least reasonable quality of evidence
and lower certainty of effect. An Intervention with Low Effect recommenda-
tion was made for interventions with at least reasonable quality of evidence
and high certainty of a low level of effect. An Intervention with Emerging
Evidence recommendation was made for interventions with lower quality of
evidence and/or certainty of effect. An Insufficient Evidence to Recommend
recommendation was made when there was an absence of evidence of effec-
tiveness or ineffectiveness.
The following criteria had to be met for a Strong recommendation:

• Quality—GRADE rating better than low or mean less than 3 for red-
rated risk of bias criteria for the meta-­analysis on which results were
based. (If the mean number of high risk of bias criteria is 3 or more, a
sensitivity analysis excluding the high-risk studies is undertaken and
used as the primary meta-­analysis if the effectiveness criterion was
met.)
96 Introduction and Background

• Effectiveness—Results met the clinical importance definition for the

primary outcome. Alternatively, results showed strong evidence of
equivalence (in head-to-head trials) to an intervention that met the
clinical importance definition. If the only results pertained to a single
RCT, over 300 participants per arm were required.
• Other factors—No other factors identified resulted in the Committee
recommending against a strong recommendation.

The following criteria had to be met for a Standard recommendation:

• Quality—GRADE rating better than low or mean less than 3 for red-
rated risk of bias criteria for the meta-­analysis on which results were
based. (If the mean number of high risk of bias criteria was 3 or more,
a sensitivity analysis excluding high-risk studies was undertaken and
used as the primary meta-­analysis if the effectiveness criterion was
met.)
• Effectiveness—Results did not meet the clinical importance definition
for the primary outcome, but the mean difference/relative risk was
greater than the threshold. If the results pertained to a single RCT,
over 100 participants per arm were required.
• Other factors—No other factors resulted in the Committee recommend-
ing against a standard recommendation.

The following criteria had to be met for an Intervention with Low Effect
recommendation:

• Quality—GRADE rating better than low or mean less than 3 for red-
rated risk of bias criteria for the meta-­analysis on which results were
based. (If the mean number of high risk of bias criteria is 3 or more,
a sensitivity analysis excluding high-risk studies was undertaken and
used as the primary meta-­analysis if the effectiveness criterion was
met.)
• Effectiveness—Results did not meet the clinical importance definition
for the primary outcome and the mean difference/relative risk was
less than the threshold. If the results pertained to a single RCT, over
300 participants per arm were required.
• Other factors—No other factors resulted in the Committee recommend-
ing against an intervention with low effect recommendation.

Intervention with Emerging Evidence was used if the quality criteria for
a strong, standard, or low effect recommendation were not met, but the
results and 95% CIs were better than the control condition. If the results
pertained to a single RCT, at least 20 participants per arm were required and
there had to be no other factors that resulted in the Committee recommend-
ing against an emerging intervention recommendation.
ISTSS Guidelines: Methodology 97

Insufficient Evidence to Recommend was used for all interventions when

the primary meta-­analysis results did not meet the clinical importance defi-
nition for the primary outcome and the 95% CIs overlapped with the point
of no difference to the control condition.
An example of a generated recommendation follows:

• Scoping question: “For adults with PTSD, do pharmacological treat-

ments, when compared to placebo, result in a clinically significant
reduction of symptoms, improved functioning/quality of life, pres-
ence of disorder, or adverse effects?”
• Recommendation: Drug X is recommended for the treatment of
adults with posttraumatic stress disorder.
• Strength of recommendation: Standard.

ISTSS Member Consultation

ISTSS members were consulted at various points of the process. Initially,

they were asked to comment on the scoping questions and methodology.
They were also asked to consider reference lists of eligible studies to deter-
mine if studies were missing. Finally, they were asked to review the initial
draft evidence summaries and recommendations, to check them for any
apparent inaccuracies, and to consider the following questions:

1. Have the agreed-­upon “rules” been applied consistently and appro-

priately with respect to the levels of recommendation made?
2. Are any studies missing?
3. Are there any apparent inaccuracies in the position papers?

Key Points to Consider in Interpreting

the Recommendations

As a result of resource constraints, the focus was on the prevention and

treatment of PTSD rather than other conditions/outcomes. The primary
outcome measure for all the scoping questions was a continuous measure of
PTSD symptoms.
The scoping questions selected did not cover all questions of relevance
to the traumatic stress field and resulted in key elements of the evidence base
not being considered. For example, community- and school-­based interven-
tions for populations in conflict zones that did not occur within 3 months
of a traumatic event were not included and studies focusing on comorbidity
were not included, unless PTSD was the primary diagnosis.
Studies that did not meet the strict inclusion criteria were not consid-
ered. This included a number of high-­quality, innovative studies such as
98 Introduction and Background

dismantling RCTs and RCTs that focused on different ways of delivering the
same intervention (e.g., face-to-face or telemedicine delivery).
The recommendations are primarily based on efficacy as determined
by meta-­analyses of RCTs. RCT evidence of effect is very important and
should strongly influence clinical decision making, but it should not dictate
it. It is important to remember the maxim, “Absence of evidence does not
mean absence of effect” and that “good health care professionals use both
individual clinical expertise and the best available external evidence, and
neither alone is enough” (Sackett, Rosenberg, Muir Gray, Haynes, & Rich-
ardson, 1996).
The studies included in the meta-­analyses cover heterogeneous settings
and populations. These and other factors—­for example, variation in therapist
competence, differences between grouped interventions, and the number of
sessions/dosage delivered—­mean that care should be taken in interpreting
recommendations and determining their implications for clinical practice.
It is possible for pharmacological, psychological, and other forms of
intervention to cause adverse effects and to be less tolerated by some indi-
viduals than others. Although there was no reason found to downgrade the
level of recommendation for any intervention on this basis, it cannot be
assumed that they will be appropriate for all PTSD sufferers.
Whatever the recommendation, interventions should only be delivered
after a thorough assessment of individuals’ needs and, where possible, a dis-
cussion between the individual (and/or caregivers) and therapist with clear
information about the evidence base, potential benefits and risks to allow
informed decision making and the development of a coproduced interven-
tion plan.

Classification and Grouping of Interventions

Various interventions have been studied for the prevention and treatment of
PTSD, and it is vital that similar and different interventions are grouped in a
meaningful way for appropriate meta-­analyses to be undertaken. The ISTSS
Guidelines Committee therefore agreed to group interventions into catego-
ries that would be widely recognized as separate by the traumatic stress com-
munity and allow discrimination between different types of intervention.
Individual meta-­ analyses were undertaken for all pharmacological
treatments identified. Psychological and other interventions for the preven-
tion and treatment of PTSD can be divided into those with a trauma focus
and those without a trauma focus, and into those delivered to individuals,
couples, or groups, but greater granularity is required to maximize the accu-
racy and usefulness of prevention and treatment recommendations. When
sufficient studies were available, the principle that interventions should
be grouped according to their broad theoretical base (e.g., CBT-T, EMDR
ISTSS Guidelines: Methodology 99

therapy, psychodynamic therapy) was used. Subgroups were then developed

if there was good evidence that a more homogeneous grouping could be
created that was based on a specific, well-­defined intervention that would
be widely recognized as a discrete intervention by individuals working in the
field (e.g., prolonged exposure, cognitive processing therapy).

Early Interventions
The following groupings/subgroupings were agreed upon for early interven-
tions:

A. Interventions with a trauma focus

1. Brief eye movement desensitization and reprocessing (EMDR ther-
apy). EMDR therapy is a standardized, eight-phase, trauma-­focused
therapy involving the use of bilateral physical stimulation (eye move-
ments, taps, or tones). Targeted traumatic memories are considered
in terms of an image, the associated cognition, the associated affect,
and body sensation. These four components are then focused on as
bilateral physical stimulation occurs. It is hypothesized that EMDR
therapy stimulates the individual’s own information processing to
help integrate the targeted memory as an adaptive contextualized
memory. Processing targets involve past events, present triggers, and
adaptive future functioning. EMDR therapy at times uses restricted
questioning related to cognitive processes paired with bilateral stim-
ulation to unblock processing.
2. Brief individual trauma processing therapy. This subgroup con-
sisted of a number of brief therapies—­lasting two or more sessions—­
that were theoretically diverse but shared similar core treatment
components. These included psychoeducation and therapist-­directed
reliving of the index trauma to promote elaboration of the trauma
memory and help to contextualize or reframe aspects of the experi-
ence.
3. Cognitive-­behavioral therapy with a trauma focus (CBT-T). CBT-T
includes all therapies that aim to help PTSD sufferers and those dis-
playing early traumatic stress symptoms by addressing and changing
their thoughts, beliefs, and/or behavior. Typically, CBT-T involves
homework and includes psychoeducation, exposure work, cognitive
work, and more general relaxation/stress management; the relative
contribution of these elements varies between different forms of
CBT-T.
4. Debriefing. The debriefing interventions are single-­ session and
based on critical incident stress debriefing; individuals are asked to
provide detailed facts of what happened, their thoughts, reactions,
100 Introduction and Background

and symptoms before being provided with psychoeducation about

symptoms and how to deal with them.
5. Group 512 PM. Group 512 PM is based on debriefing but supple-
mented with cohesion training exercises, for example, playing games
that require team cooperation.
6. Internet virtual reality therapy. This involves CBT-T delivered
through a virtual reality therapy room, rather than face-to-face.
7. Nurse-led intensive care recovery program. This intervention,
based on several models, involved delivery of a nurse-led psychologi-
cal intervention aimed at developing a narrative about the individu-
al’s admission and stay in an intensive care unit.
8. Stepped/collaborative care (SCC). SCC involves the provision
of flexible and modular interventions based on needs identified
through screening and direct assessment. Individuals may be offered
a range of different psychological interventions based on identified
need. Intervention is normally CBT based, but sometimes based on
other psychological approaches (e.g., motivational interviewing) and
may include components of case management and prescription of
pharmacological intervention.
9. Structured writing therapy (SWT). SWT involves individuals under-
taking guided homework-­ based writing assignments about their
trauma experience and their thoughts and feelings. SWT does not
involve the teaching or practice of cognitive therapy-­ based tech-
niques.
10. Telephone-­based CBT-T. CBT-T delivered by telephone, rather than
face-to-face.
B. Interventions without a trauma focus
1. Behavioral activation (BA). BA aims to help the individual learn to
manage negative feelings through activity planning. Core features
of intervention include psychoeducation, behavioral analysis, activ-
ity planning, goal identification, troubleshooting, homework, and
relapse prevention.
2. Brief dyadic therapy. This subgroup consisted of brief CBT-based
therapies delivered dyadically with the aim of improving communica-
tion and fostering a shared approach to addressing psychological and
practical difficulties.
3. Brief interpersonal psychotherapy (IPT). IPT focuses on individu-
als’ social and interpersonal functioning and helps patients develop
skills in social interactions and social support mobilization. The focus
is on current interpersonal encounters rather than past trauma.
4. Brief parenting intervention. This intervention is delivered follow-
ing premature birth primarily focused on supporting the interaction
between the neonate and mother.
ISTSS Guidelines: Methodology 101

5. Cognitive therapy. This includes a variety of non-­trauma-­focused

techniques commonly used in generic CBT, including, but not limited
to, stress management, emotional stabilization, relaxation training,
breathing retraining, positive thinking and self-talk, assertiveness
training, thought stopping, and stress inoculation training. Cogni-
tive therapy does not involve exposure to trauma memories with the
aim of undertaking reprocessing.
6. Communication facilitator in an intensive care setting. This
approach involves intervention aimed at trying to understand the
needs of patients and their families in an intensive care setting and
active liaison between clinicians and patients and family members to
improve communication and expectations.
7. Computerized neurobehavioral training. This intervention aims
to teach participants skills to improve neurocognitive functioning
through an online program. Participants are encouraged to practice
new skills through regular practice.
8. Computerized visuospatial task. This involves playing a computer
game (e.g., Tetris) to disrupt consolidation of trauma memories.
9. Intensive care diaries. This approach is based on the provision of
postdischarge daily feedback to patients admitted to intensive care
units to help promote an understanding of events that occurred dur-
ing their admission.
10. Self-­g uided Internet-­based intervention. This approach uses Internet-­
based programs to treat PTSD sufferers using CBT approaches. Use
of the intervention is self-­directed.
11. Supportive/nondirective counseling (SC). SC involves active,
empathic listening to the patient who is usually provided with uncon-
ditional positive regard. The therapist helps the patient to explore
and clarify issues, may provide advice, reflect and confirm appro-
priate reactions, and introduce problem-­solving techniques. SC has
been used as a non-­ t rauma-­
focused control condition in several
trials, and focused attention on the index trauma event is usually
avoided.
12. Supported psychoeducational intervention. This intervention
involves the provision of psychoeducational information, normally
in booklet or leaflet form, with follow-­up guidance, typically by tele-
phone, aimed at reinforcing use of the psychoeducational material.
13. Telephone-­based CBT. CBT delivered by telephone, rather than
face-to-face.

Treatment Interventions
The following groupings/subgroupings were agreed upon for treatment
interventions:
102 Introduction and Background

A. Psychological interventions with a trauma focus

1. CBT-T. CBT-T includes all therapies that aim to help PTSD suffer-
ers by addressing and changing their thoughts, beliefs, and/or behav-
ior. Typically, CBT-T involves homework and includes psychoeduca-
tion, exposure work, cognitive work, and more general relaxation/
stress management; the relative contribution of these elements varies
between different forms of CBT-T.
For children and adolescents, separate meta-­analyses were under-
taken for CBT-T delivered to child/adolescent only, child/adolescent
and caregiver, and caregiver only. TF-CBT is a specific, phase-based
model of CBT-T delivered to child/adolescent and caregiver. The first
phase includes affect regulation skills and the second phase process-
ing of the trauma narrative. Gradual exposure is incorporated into
all components to enhance the child’s/adolescent’s and caregiver’s
mastery of trauma reminders. Caregivers are included, when possible,
throughout treatment to support the child’s/adolescent’s practice and
mastery of skills and to enhance positive parenting and parental sup-
port.
For adults, the following therapies have been included in meta-­
analyses as subgroups of CBT-T for individuals or couples (there were
not enough RCTs of different types of group therapy to allow mean-
ingful subgroup analyses):
a. Brief eclectic psychotherapy for PTSD (BEPP). BEPP draws on ele-
ments of CBT-T and psychodynamic therapy, including the relation-
ship between the patient and the therapist. It includes exposure to
traumatic memories, therapeutic letter writing, and consideration
of how the individual has been affected by his or her experience(s).
BEPP usually ends with a farewell ritual.
b. Cognitive therapy for PTSD (CT-PTSD). CT-PTSD focuses on the
identification and modification of negative appraisals and behav-
iors that lead the PTSD sufferer to overestimate current threat
(fear). It also involves modification of beliefs related to other
aspects of the experience and how the individual interprets his or
her behavior during the trauma (e.g., issues concerning guilt and
shame).
c. Cognitive processing therapy (CPT). The main focus of CPT is on
the evaluation and modification of problematic thoughts that have
developed following the traumatic experience(s). For example,
using cognitive techniques to challenge typical thoughts of PTSD,
that the individual is to blame for his or her trauma or that the
world is now unsafe. An optional component of CPT is the develop-
ment of a detailed written narrative account of the trauma.
d. Internet-­based CBT-T. Internet-­based CBT-T uses Internet-­ based
programs to treat PTSD sufferers using CBT-T approaches. A
ISTSS Guidelines: Methodology 103

therapist who has less contact with the patient than in traditional
face-to-face CBT-T often guides Internet-­based CBT-T.
e. Narrative exposure therapy (NET). NET allows PTSD sufferers to
describe and develop a coherent, chronological, autobiographical
narrative of their life that includes their traumatic experiences (a
testimony). The therapist facilitates emotional processing through
the use of cognitive-­ behavioral techniques. A modified version
(KidNET) has been developed for children.
f. Prolonged exposure (PE). The primary focus of PE is to help the
PTSD sufferer to confront her or his traumatic memories using a
verbal narrative technique that involves detailed recounting of the
traumatic experience, which is then recorded and listened to on a
repeated basis with the goal of habituation. In addition, real-life
repeated exposure to avoided and fear-­evoking situations, which
are now safe but associated with the trauma, is undertaken, again
with the aim of habituation.
g. Reconsolidation of traumatic memories (RTM). RTM involves acti-
vation of a traumatic memory and a subsequent procedure that
includes imagining a black-and-white movie of the event, dissoci-
ated from its content, and rewinding it when fully associated over
2 seconds. This is designed to change the perspective from which
a memory is recalled.
h. Virtual reality therapy (VRT). VRT involves the PTSD sufferer
being exposed to a computer-­generated virtual reality that is rep-
resentative of the individual’s traumatic experience(s). A therapist
is present and regulates the amount of exposure according to the
patient’s response. The aim is to achieve habituation.
i. Written emotional disclosure (WED). WED involves the PTSD suf-
ferer writing about his or her traumatic experience(s) based on
the belief that suppressed thoughts and emotions maintain PTSD
symptoms and accessing, expressing, and processing them will be
beneficial.
2. Dialogical exposure therapy (DET). DET uses CBT techniques (with
and without a trauma focus) and a Gestalt-­based exposure method
(chair work) in a dialogical framework. Supported by the therapist,
the individual enters into a dialogue with aspects of the traumatic
experience.
3. Emotional freedom techniques (EFT). EFT is a trauma-­focused inter-
vention that involves recalling a traumatic event and pairing it with a
statement of self-­acceptance. This statement is verbally repeated while
energy meridians used in acupuncture are stimulated using finger
taps rather than needles.
4. EMDR therapy. EMDR therapy is a standardized, eight-phase, trauma-­
focused therapy involving the use of bilateral physical stimulation (eye
104 Introduction and Background

movements, taps, or tones). Targeted traumatic memories are consid-

ered in terms of an image, the associated cognition, the associated
affect, and body sensation. These four components are then focused
on as bilateral physical stimulation occurs. It is hypothesized that
EMDR therapy stimulates the individual’s own information processing
to help integrate the targeted memory as an adaptive contextualized
memory. Processing targets involve past events, present triggers, and
adaptive future functioning. EMDR therapy at times uses restricted
questioning related to cognitive processes paired with bilateral stimu-
lation to unblock processing.
5. Observed and experiential integration (OEI). OEI involves alter-
nately covering and uncovering the eyes (“switching”) and the eyes
tracking different locations in the visual field (“glitch-­work”) while
experiencing a disturbing thought, feeling, or memory. It also includes
observation of differences between the two eyes’ perceptions.
6. Rapid eye movement desensitization (REM-D). REM-D initially
involves conditioning soothing images with a calming piece of music.
Individuals then wear glasses during sleep that detect rapid eye move-
ments (as would occur during dreams) and activate playing of the
same piece of music for a period of 30 seconds with the aim of desen-
sitization during nightmares.
B. Psychological and other interventions without a trauma focus
1. Acupuncture. Acupuncture involves the insertion of fine needles at
specific points on the body (acupressure points) to reduce symptoms
of PTSD.
2. Attentional bias modification (ABM). ABM is a treatment designed
for the management of anxiety disorders based on the finding that
patients with anxiety disorders selectively attend to threatening infor-
mation. It involves computer-­based training to divert attention away
from threatening information.
3. CBT without a trauma focus. This includes a heterogeneous group
of therapies that use a variety of non-­ trauma-­ focused techniques
commonly used in generic CBT, including, but not limited to, stress
management, emotional stabilization, relaxation training, breath-
ing retraining, positive thinking and self-talk, assertiveness training,
thought stopping, and stress inoculation training.
4 Hypnotherapy. Hypnotherapy uses hypnosis to induce an altered
state of consciousness before undertaking therapeutic work.
5. IPT. IPT is an attachment-­based treatment that focuses on current
interpersonal problems and the resolution of these to improve symp-
toms.
6. Mantram repetition. This involves repeating a holy word(s) or
phrase(s).
ISTSS Guidelines: Methodology 105

7. Metacognitive therapy (MT). MT involves a focus on metacognition,

the aspect of cognition that controls our thinking and conscious
experience. MC aims to change unhelpful thinking patterns that may
be maintaining symptoms by addressing the metacognitive beliefs
that give rise to them.
8. Mind–body skills. Mind–body skills include various techniques,
including mindfulness, meditation, guided imagery, expressive draw-
ing and writing, self-­hypnosis, and biofeedback.
9. Mindfulness-­based stress reduction (MBSR). MBSR aims to help
individuals experience traumatic memories without significant dis-
tress by facilitating acceptance of them. MBSR includes meditation
practice, mindful awareness practice, and its application to real-life
situations.
10. Neurofeedback. Neurofeedback involves real-time displays of brain
activity that are used to help individuals train (self-­regulate) their
brain activity.
11. Parent–­child relationship enhancement. Parent–­child relationship
enhancement describes therapies that use different techniques, for
example, play, with a primary focus to improve parent–­child relation-
ships.
12. Present-­centered therapy (PCT). PCT is designed to target daily
challenges that PTSD sufferers encounter as a result of their symp-
toms. It includes psychoeducation about the impact of PTSD symp-
toms, the development of effective strategies to deal with day-to-day
challenges, and homework to practice newly developed skills.
13. Psychodynamic therapy. Psychodynamic therapy uses psycho-
analytic theories and practices to help individuals understand and
resolve their problems by increasing awareness of their inner world
and its influences over current and past relationships.
14. Psychoeducation. Psychoeducation provides individuals with infor-
mation about traumatic stress reactions, PTSD, and how to manage
them.
15. Saikokeishikankyoto. This is a traditional Japanese herbal medicine.
16. Somatic experiencing. This involves a focus on perceived body sen-
sations and to learn how to regulate these with the aim of resolving
symptoms.
17. Stepped- ­care CBT-T. This is an intervention developed for children
with the introduction of a first step (before therapist-­led CBT-T) of
parent-­led treatment supported by a therapist and Web-based materi-
als. If children require more treatment, they then receive CBT-T.
18. Supportive/nondirective counseling (SC). SC involves active,
empathic listening to the patient, who is usually provided with uncon-
ditional positive regard. The therapist helps the patient to explore
106 Introduction and Background

and clarify issues, may provide advice, reflect and confirm appropri-
ate reactions, and introduce problem-­solving techniques.
19. Transcranial magnetic stimulation (TMS). TMS uses magnetic
fields to stimulate nerve cells in targeted areas of the brain. It is usu-
ally given in a repetitive manner and is noninvasive.
20. Yoga. Yoga is an integrative practice of body postures, breathing, and
meditation. It aims to increase present-­focused attention and aware-
ness and to facilitate mindfulness and acceptance.

REFERENCES

Australian Centre for Posttraumatic Mental Health. (2007). Australian guidelines for
the treatment of adults with acute stress disorder and posttraumatic stress disorder.
Melbourne, Australia: Author.
Higgins, J. P. T., & Green, S. (Eds.). (2011, March). Cochrane handbook for sys-
tematic reviews of interventions, Version 5.1.0. Retrieved from http://training.
cochrane.org/handbook.
National Institute for Health and Clinical Excellence. (2005). Post-­traumatic stress
disorder. London: Royal College of Psychiatrists & the British Psychological
Society.
Sackett, D., Rosenberg, W., Muir Gray, J., Haynes, R., & Richardson, W. (1996). Evi-
dence based medicine: What it is and what it isn’t. British Medical Journal, 312,
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World Health Organization. (2013). Guidelines for the management of conditions specifi-
cally related to stress. Geneva, Switzerland: Author.

APPENDIX 6.1. ISTSS Committee for the Development

of the PTSD Prevention and Treatment Guidelines
Lucy Berliner Candice M. Monson
Jonathan I. Bisson (Chair) Miranda Olff
Marylene Cloitre Stephen Pilling
David Forbes (Vice Chair) David S. Riggs
Lutz Goldbeck1 Neil P. Roberts
Tine Jensen1 Francine Shapiro2
Catrin Lewis

1 LutzGoldbeck tragically died on October 30, 2017, and Tine Jensen subsequently joined the Com-
mittee.
2 Francine Shapiro tragically died on June 16, 2019, following completion of the guidelines and her

contributions to this volume.

ISTSS Guidelines: Methodology 107

APPENDIX 6.2. Scoping Questions

1. For children and adolescents within the first 3 months of a traumatic event, do
psychosocial interventions, when compared to intervention as usual, waiting
list, or no intervention, result in a clinically important reduction/prevention
of symptoms, improved functioning/quality of life, presence of disorder, or
adverse effects?
2. For children and adolescents within the first 3 months of a traumatic event,
do psychosocial interventions, when compared to other psychosocial inter-
ventions, result in a clinically important reduction/prevention of symptoms,
improved functioning/quality of life, presence of disorder, or adverse effects?
3. For adults within the first 3 months of a traumatic event, do psychosocial
interventions, when compared to intervention as usual, waiting list, or no
intervention, result in a clinically important reduction/prevention of symp-
toms, improved functioning/quality of life, presence of disorder, or adverse
effects?
4. For adults within the first 3 months of a traumatic event, do psychosocial
interventions, when compared to other psychosocial interventions, result in a
clinically important reduction/prevention of symptoms, improved function-
ing/quality of life, presence of disorder, or adverse effects?
5. For children and adolescents within the first 3 months of a traumatic event, do
pharmacological interventions, when compared to placebo, result in a clini-
cally important reduction/prevention of symptoms, improved functioning/
quality of life, presence of disorder, or adverse effects?
6. For children and adolescents within the first 3 months of a traumatic event, do
pharmacological interventions, when compared to other pharmacological or
psychosocial interventions, result in a clinically important reduction/preven-
tion of symptoms, improved functioning/quality of life, presence of disorder,
or adverse effects?
7. For adults within the first 3 months of a traumatic event, do pharmacologi-
cal interventions, when compared to placebo, result in a clinically important
reduction/prevention of symptoms, improved functioning/quality of life, pres-
ence of disorder, or adverse effects?
8. For adults within the first 3 months of a traumatic event, do pharmacological
interventions, when compared to other pharmacological or psychosocial inter-
ventions, result in a clinically important reduction/prevention of symptoms,
improved functioning/quality of life, presence of disorder, or adverse effects?
9. For children and adolescents with clinically relevant posttraumatic stress
symptoms, do psychological treatments, when compared to treatment as usual,
waiting list, or no treatment, result in a clinically important reduction of symp-
toms, improved functioning/quality of life, presence of disorder, or adverse
effects?
10. For children and adolescents with clinically relevant posttraumatic stress
symptoms, do psychological treatments, when compared to other psycho-
logical treatments, result in a clinically important reduction of symptoms,
improved functioning/quality of life, presence of disorder, or adverse effects?
108 Introduction and Background

11. For adults with PTSD, do psychological treatments, when compared to treat-
ment as usual, waiting list, or no treatment, result in a clinically important
reduction of symptoms, improved functioning/quality of life, presence of
disorder, or adverse effects?
12. For adults with PTSD, do psychological treatments, when compared to other
psychological treatments, result in a clinically important reduction of symp-
toms, improved functioning/quality of life, presence of disorder, or adverse
effects?
13. For children and adolescents with clinically relevant posttraumatic stress
symptoms, do pharmacological treatments, when compared to placebo, result
in a clinically important reduction of symptoms, improved functioning/quality
of life, presence of disorder, or adverse effects?
14. For children and adolescents with clinically relevant posttraumatic stress
symptoms, do pharmacological treatments, when compared to other pharma-
cological or psychosocial interventions, result in a clinically important reduc-
tion of symptoms, improved functioning/quality of life, presence of disorder,
or adverse effects?
15. For adults with PTSD, do pharmacological treatments, when compared to
placebo, result in a clinically important reduction of symptoms, improved
functioning/quality of life, presence of disorder, or adverse effects?
16. For adults with PTSD, do pharmacological treatments, when compared to
other pharmacological or psychosocial interventions, result in a clinically
important reduction of symptoms, improved functioning/quality of life, pres-
ence of disorder, or adverse effects?
17. For children and adolescents with clinically relevant posttraumatic stress
symptoms, do nonpsychological and nonpharmacological treatments/inter-
ventions, when compared to treatment as usual, waiting list, or no treatment,
result in a clinically important reduction of symptoms, improved functioning/
quality of life, presence of disorder, or adverse effects?
18. For children and adolescents with clinically relevant posttraumatic stress
symptoms, do nonpsychological and nonpharmacological treatments/inter-
ventions, when compared to other treatments, result in a clinically important
reduction of symptoms, improved functioning/quality of life, presence of
disorder, or adverse effects?
19. For adults with PTSD, do nonpsychological and nonpharmacological treat-
ments/interventions, when compared to treatment as usual, waiting list, or no
treatment, result in a clinically important reduction of symptoms, improved
functioning/quality of life, presence of disorder, or adverse effects?
20. For adults with PTSD, do nonpsychological and nonpharmacological treat-
ments/interventions when compared to other treatments, result in a clinically
important reduction of symptoms, improved functioning/quality of life, pres-
ence of disorder, or adverse effects?
C H A P TE R 7

ISTSS PTSD Prevention

and Treatment Guidelines
Recommendations

Jonathan I. Bisson, Lucy Berliner, Marylene Cloitre,

David Forbes, Tine Jensen, Catrin Lewis, Candice M. Monson,
Miranda Olff, Stephen Pilling, David S. Riggs, Neil P. Roberts,
and Francine Shapiro

Tpretation,
he ISTSS guidelines recommendations should be used with an under-
standing of the methodology and the key points to consider in their inter-
as described in the prior chapter. The recommendations for spe-
cific early interventions and treatments are listed under summaries of the
relevant scoping questions. The recommendations are grouped according
to the five different levels of strength of recommendation possible: Strong,
Standard, Low Effect, Intervention with Emerging Evidence, and Insufficient Evi-
dence to Recommend. For an intervention or treatment to be listed, there must
have been at least one randomized controlled trial included in at least one
of the meta-­analyses undertaken to answer the relevant scoping questions.
The recommendations were generated with the information available to
the ISTSS Guidelines Committee on October 10, 2018; as more knowledge
becomes available, it is likely that the level of some of the recommendations
will change.

Children and Adolescents

Early Psychosocial Intervention
Summary of relevant scoping questions: “For children and adolescents within
the first 3 months of a traumatic event, do psychosocial interventions, when
compared to intervention as usual, waiting list, no intervention, or other
psychosocial interventions, result in a clinically important reduction/pre-
vention of symptoms, improved functioning/quality of life, presence of dis-
order, or adverse effects?”

109
110 Introduction and Background

Early Preventative Interventions1

Intervention with Emerging Evidence—Self-­directed online psychoeducation for
caregivers and children and self-­directed online psychoeducation for children
within the first 3 months of a traumatic event have emerging evidence
of efficacy for the prevention of clinically relevant posttraumatic stress
symptoms in children and adolescents.
Emerging Evidence Not to Recommend—Individual psychological debriefing
within the first 3 months of a traumatic event has emerging evidence of
increasing the risk of clinically relevant posttraumatic stress symptoms
in children and adolescents.
Insufficient Evidence to Recommend—There is insufficient evidence to recom-
mend brief CBT-T or self-­directed online psychoeducation for caregivers only
within the first 3 months of a traumatic event for the prevention of clini-
cally relevant posttraumatic stress symptoms in children and adolescents.

Early Treatment Interventions2

Insufficient Evidence to Recommend—There is insufficient evidence to recom-
mend brief CBT-T, CBT-T, or stepped preventative care within the first 3
months of a traumatic event for the treatment of clinically relevant post-
traumatic stress symptoms in children and adolescents.

Early Pharmacological Intervention

Summary of relevant scoping questions: “For children and adolescents within the
first 3 months of a traumatic event, do pharmacological interventions, when
compared to placebo, other pharmacological, or psychosocial interventions,
result in a clinically important reduction/prevention of symptoms, improved
functioning/quality of life, presence of disorder, or adverse effects?”

Insufficient Evidence to Recommend—There is insufficient evidence to recom-

mend propranolol within the first 3 months of a traumatic event as an
early pharmacological intervention to prevent clinically relevant post-
traumatic stress symptoms in children and adolescents.

Psychological Treatment
Summary of relevant scoping questions: “For children and adolescents with
clinically relevant posttraumatic stress symptoms, do psychological treat-
ments, when compared to treatment as usual, waiting list, no treatment, or
other psychological treatments, result in a clinically important reduction of
symptoms, improved functioning/quality of life, presence of disorder, or
adverse effects?”
1 Targeted at unscreened or minimally screened populations.
2 Provided to individuals with emerging traumatic stress symptoms.
ISTSS Guidelines: Recommendations 111

Strong Recommendation—CBT-T (caregiver and child), CBT-T (child), and EMDR

therapy are recommended for the treatment of children and adolescents
with clinically relevant posttraumatic stress symptoms.
Intervention with Emerging Evidence—Group CBT-T (child), group psychoeduca-
tion, and parent–­child relationship enhancement have emerging evidence
of efficacy for the treatment of children and adolescents with clinically
relevant posttraumatic stress symptoms.
Insufficient Evidence to Recommend—There is insufficient evidence to recom-
mend CBT-T (caregiver), family therapy, group CBT-T (caregiver and child),
KidNET, nondirective counseling, or stepped-­care CBT-T (caregiver and child)
for the treatment of children and adolescents with clinically relevant
posttraumatic stress symptoms.

Pharmacological Treatment
Summary of relevant scoping questions: “For children and adolescents with clini-
cally relevant posttraumatic stress symptoms, do pharmacological treatments,
when compared to placebo, other pharmacological, or psychosocial interven-
tions, result in a clinically important reduction of symptoms, improved func-
tioning/quality of life, presence of disorder, or adverse effects?”

Insufficient Evidence to Recommend—There is insufficient evidence to recom-

mend sertraline for the treatment of children and adolescents with clini-
cally relevant posttraumatic stress symptoms.

Nonpsychological and Nonpharmacological Treatment

Summary of relevant scoping questions: “For children and adolescents with
clinically relevant posttraumatic stress symptoms, do nonpsychological and
nonpharmacological treatments/interventions, when compared to treat-
ment as usual, waiting list, no treatment, or other treatments, result in a
clinically important reduction of symptoms, improved functioning/quality
of life, presence of disorder, or adverse effects?”

Insufficient Evidence to Recommend—There is insufficient evidence to recom-

mend mind–body skills or trauma-­focused expressive art therapy for the treat-
ment of children and adolescents with clinically relevant posttraumatic
stress symptoms.

Adults
Early Psychosocial Intervention
Summary of relevant scoping questions: “For adults within the first 3 months
of a traumatic event, do psychosocial interventions, when compared to
intervention as usual, waiting list, no intervention, or other psychosocial
112 Introduction and Background

interventions, result in a clinically important reduction/prevention of symp-

toms, improved functioning/quality of life, presence of disorder, or adverse
effects?”

Single‑Session Interventions
Intervention with Emerging Evidence—Group 512 PM and single- ­session EMDR
therapy within the first 3 months of a traumatic event have emerging evi-
dence of efficacy for the prevention and treatment of PTSD symptoms
in adults.
Insufficient Evidence to Recommend—There is insufficient evidence to rec-
ommend group debriefing, group education, group stress management, heart
stress counseling, individual debriefing, individual psychoeducation/self-help,
reassurance, single-­session computerized visuospatial task, or trauma-­focused
counseling within the first 3 months of a traumatic event for the preven-
tion or treatment of PTSD symptoms in adults.

Multiple‑Session Prevention Interventions3

Intervention with Emerging Evidence—Brief dyadic therapy and self-­g uided
Internet-­based intervention within the first 3 months of a traumatic event
have emerging evidence of efficacy for the prevention of PTSD symp-
toms in adults.
Insufficient Evidence to Recommend—There is insufficient evidence to rec-
ommend brief individual trauma processing therapy, brief IPT, brief parent-
ing intervention following premature birth, collaborative care, communication
facilitator in an intensive care setting, intensive care diaries in an intensive
care context, nurse-led intensive care recovery program, supported psychoeduca-
tional intervention, or telephone-­based CBT within the first 3 months of a
traumatic event for the prevention of PTSD symptoms in adults.

Multiple‑Session Early Treatment Interventions4

Standard Recommendation—CBT-T, cognitive therapy, and EMDR therapy
within the first 3 months of a traumatic event are recommended for the
treatment of PTSD symptoms in adults.
Intervention with Low Effect—Stepped/collaborative care within the first 3
months of a traumatic event is recommended as a low effect treatment
of PTSD symptoms in adults.
Intervention with Emerging Evidence—Internet-­based guided self-help and struc-
tured writing intervention within the first 3 months of a traumatic event

3 Targeted at unscreened or minimally screened populations.

4 Provided to individuals with emerging traumatic stress symptoms.
ISTSS Guidelines: Recommendations 113

have emerging evidence of efficacy for the treatment of PTSD symp-

toms in adults.
Insufficient Evidence to Recommend—There is insufficient evidence to recom-
mend behavioral activation, computerized neurobehavioral training, Inter-
net virtual reality therapy, supportive counseling, or telephone-­based CBT-T
within the first 3 months of a traumatic event for the treatment of PTSD
symptoms in adults.

Early Pharmacological Intervention

Summary of relevant scoping questions: “For adults within the first 3 months
of a traumatic event, do pharmacological interventions, when compared to
placebo, other pharmacological, or psychosocial interventions, result in a
clinically important reduction/prevention of symptoms, improved function-
ing/quality of life, presence of disorder, or adverse effects?”

Intervention with Emerging Evidence—Hydrocortisone within the first 3 months

of a traumatic event has emerging evidence of efficacy for the preven-
tion of PTSD symptoms in adults.
Insufficient Evidence to Recommend—There is insufficient evidence to recom-
mend docosahexaenoic acid, escitalopram, gabapentin, oxytocin, or proprano-
lol within the first 3 months of a traumatic event for the prevention or
treatment of PTSD symptoms in adults.

Psychological Treatment
Summary of relevant scoping questions: “For adults with PTSD, do psycho-
logical treatments, when compared to treatment as usual, waiting list, no
treatment, or other psychological treatments, result in a clinically important
reduction of symptoms, improved functioning/quality of life, presence of
disorder, or adverse effects?”

Strong Recommendation—Cognitive processing therapy, cognitive therapy, EMDR

therapy, individual CBT with a trauma focus (undifferentiated),5 and pro-
longed exposure are recommended for the treatment of adults with PTSD.
Standard Recommendation—CBT without a trauma focus, group CBT with a
trauma focus, guided Internet-­based CBT with a trauma focus, narrative expo-
sure therapy, and present-­centered therapy are recommended for the treat-
ment of adults with PTSD.
Intervention with Emerging Evidence—Couples CBT with a trauma focus, group
and individual CBT with a trauma focus, reconsolidation of traumatic memo-
ries, single- ­session CBT, virtual reality therapy, and written exposure therapy

5 The individual CBT with a trauma focus (undifferentiated) recommendation is made from

a meta-­a nalysis of all studies meeting the CBT-T definition provided in the prior chapter.
114 Introduction and Background

have emerging evidence of efficacy for the treatment of adults with

PTSD.
Insufficient Evidence to Recommend—There is insufficient evidence to rec-
ommend brief eclectic psychotherapy for PTSD, dialogical exposure therapy,
emotional freedom techniques, group interpersonal therapy, group stabilizing
treatment, group supportive counseling, interpersonal psychotherapy, observed
and experimental integration, psychodynamic psychotherapy, psychoeducation,
relaxation training, REM desensitization, or supportive counseling for the
treatment of adults with PTSD.

Pharmacological Treatment
Scoping question: “For adults with PTSD, do pharmacological treatments,
when compared to placebo, other pharmacological, or psychosocial inter-
ventions, result in a clinically important reduction of symptoms, improved
functioning/quality of life, presence of disorder, or adverse effects?”

Intervention with Low Effect—Fluoxetine, paroxetine, sertraline, and venlafaxine

are recommended as low effect treatments for adults with PTSD.
Intervention with Emerging Evidence—Quetiapine has emerging evidence of
efficacy for the treatment of adults with PTSD.
Insufficient Evidence to Recommend—There is insufficient evidence to recom-
mend amitriptyline, brofaromine, divalproex, ganaxolone, imipramine, ket-
amine, lamotrigine, mirtazapine, neurokinin-1 antagonist, olanzapine, phen-
elzine, tiagabine, or topiramate for the treatment of adults with PTSD.

Nonpsychological and Nonpharmacological Treatment

Summary of relevant scoping questions: “For adults with PTSD, do nonpsycho-
logical and nonpharmacological treatments/interventions, when compared
to treatment as usual, waiting list, no treatment, or other treatments, result
in a clinically important reduction of symptoms, improved functioning/
quality of life, presence of disorder, or adverse effects?”

Intervention with Emerging Evidence—Acupuncture, neurofeedback, saikokei-

shikankyoto, somatic experiencing, transcranial magnetic stimulation, and
yoga have emerging evidence of efficacy for the treatment of adults with
PTSD.
Insufficient Evidence to Recommend—There is insufficient evidence to recom-
mend attentional bias modification, electroacupuncture, group mindfulness-­
based stress reduction, group music therapy, hypnotherapy, mantram repeti-
tion, mindfulness-­based stress reduction, nature adventure therapy, or physical
exercise for the treatment of adults with PTSD.
PA R T II

EARLY INTERVENTION
IN ADULTS
C H A P TE R 8

Early Intervention
for Trauma‑Related Psychopathology
Meaghan L. O’Donnell, Belinda J. Pacella, Richard A. Bryant,
Miranda Olff, and David Forbes

Itionnrelated
many ways, posttraumatic stress disorder (PTSD) and other trauma-­
psychopathology are the primary candidates for early interven-
because in all instances a discrete event(s) precipitates the disorder.
It is seductive to think that if we can identify who has been exposed to the
traumatic event, we can identify who would benefit from early intervention.
Unfortunately, the process is not quite that easy. Before examining the effi-
cacy and effectiveness of interventions designed to prevent and/or treat the
mental health impacts of trauma exposure, it is important to consider how
early intervention has been understood from different perspectives.

Background and Context

What Is Early Intervention?
There is no doubt that early intervention is a confusing term, especially in
the context of mental health. Often early intervention is described in terms
of preventing the prevalence and incidence of disorder (Magruder, Kassam-­
Adams, Thoresen, & Olff, 2016; Magruder, McLaughlin, & Elmore Borbon,
2017). Primary and secondary prevention are terms frequently used when
discussing early intervention in health contexts. Primary prevention aims
to prevent a disease before it occurs by preventing exposures to hazards
that cause the disease. Secondary prevention aims to reduce the impact of
disease that has already occurred by detecting and treating disease as soon
as possible. In a trauma context, primary prevention would be activities that
decrease the risk of being exposed to traumatic events, such as increasing

117
118 Early Intervention in Adults

lighting on campus to prevent sexual assault. Secondary prevention would be

all activities designed to decrease the risk of trauma psychopathology devel-
oping once exposed to trauma, such as treating acute stress disorder (ASD)
to prevent the development of PTSD. Other more complex models have built
on the primary/secondary prevention approach, such as a social-­ecological
model developed by the International Society for Traumatic Stress Studies
(ISTSS) that presents a multilevel approach for developing an array of strate-
gies aimed at preventing the occurrence and sequelae of trauma (Magruder
et al., 2017).
An alternative categorization of prevention may provide another use-
ful framework. The Institute of Medicine (IOM; Institute of Medicine—­
Committee on Prevention of Mental Disorders, 1994) presents a continuum
of care that provides a more graded approach to early intervention. In this
approach, early interventions fall under the prevention rubric of universal,
selective, and indicated activities. These categories of services differ accord-
ing to the level of risk of the target population. From a trauma perspective,
universal interventions are those that target the whole population of those
exposed to a traumatic event regardless of risk. Like primary prevention,
universal interventions would also include interventions designed to prevent
exposure to traumatic events. Selective interventions are those that target
individuals who risk developing disorder (but who may not yet be symp-
tomatic); indicated interventions are those that target individuals who have
minimal but detectable signs of symptoms suggesting disorder. Early treat-
ment is the delivery of an intervention shortly after an individual has devel-
oped disorder.
In this chapter, we will look at the effectiveness of early interventions
based on the results from the systematic review/meta-­analyses that under-
pinned the ISTSS treatment guidelines. These systematic reviews defined
early intervention as that beginning within 3 months of the trauma. Although
the guidelines grouped early interventions into a single prevention session,
multiple prevention sessions, and early treatment, from a clinical perspective
it is useful to consider their effectiveness from the categorization of univer-
sal, selective, indicated, and treatment of disorder. This is because not every-
one has the same emotional response to a traumatic event over time. In fact,
there are a number of distinct trajectories/patterns of PTSD symptoms after
trauma exposure, and we will argue that understanding these trajectories is
necessary when interpreting the efficacy of early interventions. Before we
describe the findings from the systematic reviews, we will take a small detour
to the literature that describes symptom trajectories after trauma exposure.

Symptom Trajectory after Trauma

In the last 5–10 years, a number of studies have used statistical methods
such as latent growth mixture modeling to examine the trajectories of PTSD
symptoms over time (Armour, Shevlin, Elklit, & Mroczek, 2012; Bonanno,
2004; Bonanno, Galea, Bucciarelli, & Vlahov, 2006; Bonanno et al., 2012;
Intervention for Trauma‑Related Psychopathology 119

Bryant et al., 2015; deRoon-­Cassini, Mancini, Rusch, & Bonanno, 2010; Fink
et al., 2017; Galatzer-­Levy et al., 2013; Lam et al., 2010; Norris, Tracy, &
Galea, 2009; Pietrzak et al., 2014; Santiago et al., 2013; Steenkamp, Dickstein,
Salters-­Pedneault, Hofmann, & Litz, 2012; Vojvoda, Weine, McGlashan,
Becker, & Southwick, 2008). Generally, these studies show that the majority
of people exposed to trauma tend to fall into one of four to five archetypi-
cal trajectories of long-term outcome. Figure 8.1 is an example of how these
trajectories are represented.
The most common outcome is a relatively stable trajectory of low symp-
tomology and healthy functioning across time (often called the resistant or
resilient group). When measured from the immediate aftermath of trauma
(i.e., within 1 to 6 months), the proportion of people in the resilient class
generally ranges from 60 to 85%, and this appears consistent across various
types of trauma (Bonanno et al., 2006, 2012; Bryant et al., 2015; deRoon-­
Cassini et al., 2010; Fink et al., 2017; Lam et al., 2010; Santiago et al., 2013).
These studies also show a second archetypical trajectory known as the
chronic class, which consists of people who have a chronic pattern of high
symptoms after trauma exposure, with these remaining high across time.

100 Chronic (4.0%)

Worsening/recovery (8.1%)
90 Recovered (5.7%)
Delayed (9.6%)
80 Resilient (72.5%)

70

60

50

40

30

20

10

0
Baseline 3 months 12 months 24 months 72 months

FIGURE 8.1. An example of the different symptom trajectories over time following
exposure to a traumatic event. From Bryant et al. (2013).
120 Early Intervention in Adults

When measured from the immediate aftermath of trauma, the proportion

of people in the chronic class ranges from 2 to 15% (Bryant, O’Donnell,
Creamer, McFarlane, & Silove, 2013; Galatzer-­Levy et al., 2013; Santiago
et al., 2013). However, proportions can reach as high as 20–35% following
severe traumatic events, such as physical assault (deRoon-­Cassini et al., 2010;
Santiago et al., 2013) and sexual assault (Armour et al., 2012).
Studies differ then about the number of remaining class trajectories and
what they look like, but generally there is a class with symptoms that start
high but then decline over time (often referred to as the recovery class), and
there is a class with symptoms that start low but then increase over time (fre-
quently described as delayed onset). Longitudinal studies have found some
variability in the proportion of people in the recovery and delayed onset
class following different types of trauma. In populations exposed to trauma
such as traumatic injury, assault, terrorism, life-­t hreatening medical proce-
dures, natural disaster, and military combat, the proportion of people in
the recovery class when measured from the immediate aftermath of trauma
ranges from 6 to 15% (Bryant et al., 2015; deRoon-­Cassini et al., 2010; Lam
et al., 2010), but can range as high as 30–40% in assault (Roy-Byrne et al.,
2004) and resettled refugee populations (Vojvoda et al., 2008). Interestingly,
in a sample of traumatic injury survivors with a high risk of PTSD, two tra-
jectories of recovery were observed: rapid remitting of symptoms within 5
months and slow remitting of symptoms within 15 months (Galatzer-­Levy et
al., 2013). However, no delayed onset class was observed. Of the discussed
studies, the proportion in the delayed onset class generally ranges from 2 to
14% (Bonanno, 2004; Bryant et al., 2015; deRoon-­Cassini et al., 2010; Norris
et al., 2009; Pietrzak et al., 2014; Santiago et al., 2013).
Contrary to these overall results that demonstrate resilience to be the
modal outcome of trauma exposure, evidence suggests that this theoretical
model may not generalize to cases of sexual assault. Rather, chronic and
recovery classes are suggested to be a distinct response to sexual assault, with
a pattern of high symptoms that decline over time (recovery) being the most
modal class. In the aftermath of sexual assault, the proportion in the recov-
ery class appears to range from 65 to 77%, and the proportion in the chronic
class ranges from 23 to 35% (Armour et al., 2012; Steenkamp et al., 2012).
Recognizing these PTSD symptom trajectories/patterns (1) helps
us interpret the findings from the systematic review/meta-­ analyses and
(2) going forward helps us think about how and when to target interven-
tions. Let us first look at the results from the literature reviews with these
trajectories in mind.

Summary and Appraisal of the Evidence

The following tables introduce the findings of the ISTSS guideline recom-
mendations for posttrauma intervention. Table 8.1 presents the findings for
a single prevention session, and Table 8.2 gives the outcomes for multiple
Intervention for Trauma‑Related Psychopathology 121

TABLE 8.1. ISTSS Recommendations for Single Prevention Session

Early Interventions
Intervention with Emerging Evidence—EMDR therapy, Group 512 PM
Insufficient Evidence to Recommend—Computerized visuospatial task,
group debriefing: group education, group stress management, heart
stress counseling, individual debriefing, psychoeducation/self-help,
reassurance, trauma-focused counseling

TABLE 8.2. ISTSS Recommendations for Multiple Prevention Session

Early Interventions
Intervention with Emerging Evidence—Brief dyadic therapy, self-guided
Internet-based intervention
Insufficient Evidence to Recommend—Brief IPT, brief individual
trauma processing therapy, brief parenting intervention following
premature birth, collaborative care, communication facilitator in
an intensive care setting, guided self-help, intensive care diaries in
an intensive care context, self-guided Internet-based intervention,
supported psychoeducational intervention, telephone-based CBT

TABLE 8.3. ISTSS Recommendations for Early Treatment

Standard Recommendation—CBT-T, cognitive therapy, EMDR therapy
Intervention with Low Effect—Stepped/collaborative care
Intervention with Emerging Evidence—Internet-based guided self-help,
structured writing intervention
Insufficient Evidence to Recommend—Behavioral activation, brief CPT,
Internet virtual reality therapy, nurse-led psychological intervention,
supportive counseling, telephone-based CBT-T

prevention sessions. Prevention interventions were defined in the guidelines

as those interventions that aim to intervene before disorder develops. Table
8.3 presents the early treatment findings defined as those interventions that
target disorders such as ASD and early PTSD within the first 3 months of
developing.
Although the ISTSS guidelines grouped early interventions into a single
prevention session, multiple prevention sessions, and early treatment, from
a clinical perspective it is useful to consider their effectiveness from the
categorization of universal, selective, indicated, and treatment of disorder.

Universal Interventions
Universal interventions target everyone who has been exposed to traumatic
events. As described previously, we know that the majority of trauma survi-
vors have low symptoms over time and will therefore recover on their own. It
122 Early Intervention in Adults

is therefore difficult to expect that universal intervention would have a sig-

nificant effect on psychiatric symptoms given that only approximately 25%
of survivors will develop moderate to high symptoms.

Single‑Session Interventions
Most of the single-­session early psychosocial interventions were universal
interventions (targeted to the whole population of trauma-­exposed survi-
vors), so it is not surprising the studies that fell into this group received a
recommendation of Insufficient Evidence to Recommend.
An Insufficient Evidence to Recommend recommendation was made when
there was an absence of evidence of effectiveness or ineffectiveness. Specifi-
cally, individual debriefing and group debriefing when delivered as a univer-
sal intervention received an Insufficient Evidence to Recommend recommenda-
tion. This finding is consistent with the 2002 Cochrane review that found
there was no evidence debriefing was useful in the prevention of PTSD
(Rose, Bisson, Churchill, & Wessely, 2002). This finding is also consistent
with the National Institute for Health and Clinical Excellence (NICE), now
the National Institute for Health and Care Excellence guidelines for PTSD
(National Institute for Health and Clinical Excellence, 2005) that recom-
mend single-­session interventions should not be a part of routine practice
(although it should be noted that the NICE Triage panel is currently updat-
ing this recommendation). Overall, the ISTSS findings are consistent with
other guidelines in recommending that single-­session psychosocial universal
interventions should not be considered a part of routine practice because of
the lack of evidence to support their use.

Multiple‑Session Interventions
Universal interventions were also not effective when delivered across mul-
tiple sessions. Specifically, when delivered as a universal intervention, brief
interpersonal counseling therapy (IPT; Holmes et al., 2007), brief individual
trauma processing therapy (Brom, Kleber, & Hofman, 1993; Gidron et al.,
2001; Rothbaum et al., 2012; Ryding, Wijma, & Wijma, 1998), brief parent-
ing intervention following premature birth (Borghini et al., 2014), intensive
care diaries (Jones et al., 2010), and collaborative care (Zatzick et al., 2001)
all received an Insufficient Evidence rating. This probably represents the fact
that the majority of trauma survivors will recover well without the assistance
of any intervention. Having said that, we have no current evidence that these
interventions would be effective if they were delivered to the minority who
would go on to develop PTSD.
Thus, if universal interventions do not seem to demonstrate efficacy
in the prevention of PTSD, what should be done after trauma exposure?
Should we indeed do anything? Currently, psychological first aid (PFA) is
the most frequently endorsed universal approach, having been adopted by
the World Health Organization (2011), Red Cross (Australian Red Cross &
Intervention for Trauma‑Related Psychopathology 123

Australian Psychological Society, 2013; Gurwitch et al., 2010), and United

Nations (Inter-­Agency Standing Committee, 2010). PFA represents a set of
actions including information provision and advice, emotional and practi-
cal support, and monitoring and referral delivered on an as-­needed basis,
and guided by the aims of promoting safety, calming, self and collectiveness
efficacy, connectedness, and hope following trauma exposure. Importantly
PFA is not intended as a formal intervention. PFA has been widely applied
by lay rescuers in public health settings and workplaces, and during critical
and traumatic events. Although PFA has widespread appeal, at least three
systematic reviews have consistently reported on the absence of studies that
provide rigorous evaluations of PFA interventions (Bisson & Lewis, 2009;
Dieltjens, Moonens, Van Praet, De Buck, & Vandekerckhove, 2014; Fox et al.,
2012). If PFA is delivered as an intervention rather than an approach, then
the need exists to empirically test its efficacy.
Alongside PFA is the approach offered by the European Network for
Traumatic Stress (TENTS; www.tentsproject.eu). TENTS provides guide-
lines for offering practical, pragmatic stupport informed by the principles
of PFA, but not as an intervention per se. Developed through a consensus
approach, these guidelines recommend against the application of formal
interventions for all individuals involved in traumatic events. This approach
is also consistent with the Australian ASD and PTSD guidelines (Phoenix
Australia—­ Centre for Posttraumatic Mental Health, 2013), which recom-
mend approaches that ensure the survivor’s safety and security, provide
ongoing practical assistance and information, and encourage the person to
use his or her social supports.

Selective/Indicated Interventions
Single‑Session Interventions
Interventions that target those with higher symptom levels start to demon-
strate more impact on preventing the development of PTSD. In the system-
atic review/meta-­analysis, two single-­session interventions were delivered
as a selective intervention (eye movement desensitization and reprocess-
ing [EMDR] therapy) or indicated intervention (Group 512 Psychological
Intervention Model [PIM]). They both received an Intervention with Emerg-
ing Evidence recommendation. Group 512 is an intervention that embeds
the unique characteristics of Chinese military rescuers within the standard
principles of critical-­incident stress debriefing (CISD) developed by Mitchell
(1983). Group 512 involves four stages—­including introduction, discussing
the facts, thoughts, reactions, and symptoms related to the trauma, followed
by stress management tips—but differs then from standard CISD by includ-
ing a final stage of cohesion training, where participants play games requir-
ing team cooperation to foster military unit cohesion. This is a critical part
of Group 512 PIM, as cohesion is said to have protective effects in preventing
stress (Armfield, 1994).
124 Early Intervention in Adults

Single-­session EMDR therapy also received an Intervention with Emerging

Evidence recommendation when delivered to trauma survivors with emerg-
ing symptoms. Single-­session EMDR therapy followed the EMDR Protocol
for Recent Critical Incidents (EMDR-PRECI). EMDR-PRECI is a modified
version of Shapiro’s Recent Traumatic Events Protocol (Shapiro & Laub,
2008), to accommodate memory consolidation that appears to change in
the weeks and months following a critical incident (Jarero, Uribe, Artigas, &
Givaudan, 2015). EMDR-PRECI involves identifying the worst fragment of
the client’s trauma memory, followed by the remaining difficult fragments
of the memory. Desensitizing occurs by having the client focus on each mem-
ory fragment while simultaneously engaging in dual-­attention stimulation
using eye movements, until all fragments have been processed and the client
no longer experiences emotional, cognitive, or somatic distress.
It is important that these two interventions undergo further treatment
trials to determine if the evidence associated with them should move both
into a higher category of recommendation.

Multiple‑Session Interventions
Multiple sessions of a selective intervention, including brief dyadic therapy
(Brunet, Des Groseilliers, Cordova, & Ruzek, 2013) and a self-­g uided Inter-
net intervention (Mouthaan et al., 2013), also received an Intervention with
Emerging Evidence recommendation. Brief dyadic therapy aims to target the
social support process following trauma exposure and involves elements of
psychoeducation and motivational interviewing to enhance communica-
tion between the patient and his or her significant other. It involves two ses-
sions that aim to promote disclosure of thoughts and emotions relating to
the trauma while attempting to reduce social constraints on disclosure and
negative interactions between the dyad (Brunet et al., 2013). Trauma TIPS,
the Internet-­based self-­g uided intervention, is based on CBT principles of
psychoeducation and stress/relaxation techniques in addition to in vivo
exposure. Trauma TIPS aims to decrease levels of distress and anxiety by
providing information on successful coping, instructions, and guidance for
in vivo exposure in addition to stress management techniques (Mouthaan et
al., 2013). Post hoc analyses showed a significant decrease in PTSD symptoms
in a subgroup of patients with severe initial symptoms, again pointing to the
importance of targeting the population at risk with higher symptoms (but
note the limitations of post hoc analyses). Although these interventions show
promise, further evidence is needed to support their efficacy.

Early Treatment
Not surprisingly, the strongest recommendations for early interventions are
made in treatments that target disorder. The majority of studies target ASD
or early PTSD.
Intervention for Trauma‑Related Psychopathology 125

Intervention with Standard Recommendations

COGNITIVE‑BEHAVIORAL THERAPY WITH A TRAUMA FOCUS

CBT with a trauma focus (CBT-T) received a Standard recommendation when

delivered as an early intervention to trauma survivors with ASD diagnosis or
early PTSD diagnosis. CBT-T is a broad term that encompasses any treatment
that employs the standard principles of CBT combined with some form of
trauma processing. Generally, CBT-T involves the integration of CBT prin-
ciples with components of exposure therapy, including imaginal exposure
and graded in vivo exposure. Across most studies, the typical format of CBT-T
included psychoeducation, breathing/relaxation training, imaginal expo-
sure, in vivo exposure, and cognitive restructuring (Bisson, Shepherd, Joy,
Probert, & Newcombe, 2004; Foa, Zoellner, & Feeny, 2006; Sijbrandij et al.,
2007; van Emmerik, Kamphuis, & Emmelkamp, 2008), but one study diverted
from this format by excluding the use of in vivo exposure (Shaw et al., 2013).
The populations within these studies consisted of a fair split of males and
females from the United States, United Kingdom, Netherlands, Australia, and
Israel, with their mean ages ranging from 33 to 40 years old; these individu-
als had been exposed to various traumatic experiences, including physical
assault, motor vehicle accidents, industrial accidents (­Bisson et al., 2004; Bry-
ant et al., 2008; Ehlers et al., 2003; Shalev et al., 2012), sexual assault (Foa et
al., 2006; van Emmerik et al., 2008), mixed trauma types (­Sijbrandij et al.,
2007), and premature births (Shaw et al., 2013).

COGNITIVE THERAPY

Cognitive therapy also received a Standard recommendation when delivered

as an early intervention to trauma survivors with PTSD symptoms. Cognitive
therapy includes identifying and challenging negative automatic thoughts,
and modifying underlying cognitive schemas, but involves less potentially
distressing exposure to traumatic recollections than other trauma-­focused
interventions. Populations within these studies (n = 2) were comparable, both
consisting of a fair split of males and females, with the mean age ranging
from 35 to 38 years old, who had been exposed to motor-­vehicle accidents,
physical injury, or terrorist attacks (Bryant et al., 2008; Shalev et al., 2012).

EMDR THERAPY

Brief EMDR therapy was the final treatment that received a Standard recom-
mendation when delivered as an early intervention to survivors with disor-
der or disorder-­level symptoms. Brief EMDR therapy can range from one
to two sessions and involves clients focusing on fragments of their trauma
memory while simultaneously engaging in dual-­attention stimulation using
eye movements. When compared to treatment as usual (TAU) or wait-list
control, EMDR therapy showed a positive effect on PTSD symptom severity
126 Early Intervention in Adults

(n = 4) (Jarero, Artigas, & Luber, 2011; Jarero et al., 2015; Shapiro & Laub,
2015; Shapiro, Laub, & Rosenblat, 2018). Across these studies, the Impact of
Event Scale (IES) and the Short PTSD Rating Interview (SPRINT) were used
to measure PTSD symptom severity. The populations within these studies
mostly included a high proportion of females (44–94%) of Mexican or Israeli
descent, with their mean ages ranging from 38 to 42, who had been exposed
to an earthquake, manufacturing factory explosion, or fatal missile attack
(Jarero et al., 2011, 2015; Shapiro & Laub, 2015; Shapiro et al., 2018).

Intervention with Emerging Evidence Recommendations

Internet-­based guided self-help and structured writing intervention received
a recommendation of Intervention with Emerging Evidence.

INTERNET‑BASED GUIDED SELF‑HELP

When compared to wait-list control or TAU, a 10-week Internet-­based guided

self-help program showed a positive effect in reducing PTSD symptoms
(measured by the PCL-C) at posttreatment for Swedish parents of children
who had been recently diagnosed with cancer. Just over a third of the sam-
ple were females, with a mean age of 38, exhibiting a high level of PTSD
symptoms. The intervention was based on CBT principles, with a focus on
psychoeducation and teaching strategies to cope with psychological distress.
Despite experiencing a high dropout rate (62%), the study suggests that
CBT-based Internet-­g uided self-help may have a substantive impact on those
who accept Internet-­based interventions and report a high level of posttrau-
matic stress symptoms.

STRUCTURED WRITING

Structured writing is a broad term that encompasses interventions that rely

exclusively on writing assignments. Of the two studies that employed struc-
tured writing interventions, one study (van Emmerik et al., 2008) adapted
its structured writing therapy program from the Interapy program, which
is an Internet-­based 10-session structured writing intervention (Lange, van
de Ven, Schrieken, & Emmelkamp, 2001). Based on the Interapy program,
the structured writing intervention followed a three-phase intervention
model involving the following phases: (1) self-­confrontation, which involves
participants writing down detailed accounts of their traumatic experience,
paying careful attention to their sensory experiences and most painful
trauma-­related emotions; (2) cognitive reappraisal, which involves writing
an (imaginal) advice letter to a friend who has experienced the same situ-
ation and then applying this advice to themselves; and (3) the sharing and
farewell phase, which involves writing a letter to a person involved in the
situation that describes the letter writer’s coping efforts. The other study
Intervention for Trauma‑Related Psychopathology 127

that employed a structured writing intervention (Bugg, Turpin, Mason, &

Scholes, 2009) based its intervention on the Pennebaker writing paradigm,
which requires participants to write about the feelings and emotions associ-
ated with their traumatic experience once a day for 3 consecutive days (Pen-
nebaker, Kiecolt-­Glaser, & Glaser, 1988). The intervention adapted this para-
digm slightly by including suggestions to participants to discuss how their
experience influenced other areas of their life, including their relationships
with loved ones or any other significant issues (Bugg et al., 2009). Across
both of these studies, participants were individuals with ASD or PTSD who
had sustained a traumatic injury, such as a traffic accident, or sexual or non-
sexual assault, with the average age ranging from 37 to 40.

Intervention with Low Effect Recommendations

A number of indicated studies took a sequencing approach. These studies
reflect an approach that could be (and are) implemented in clinical practice to
facilitate early intervention. The collaborative care model devised by ­Zatzick
(Zatzick et al., 2004, 2013, 2015) is a stepped-­care model in which injured
patients are screened for high PTSD symptoms, and those with risk factors
are offered integrated care including pharmacotherapy, motivational inter-
viewing targeting problematic alcohol use, and CBT targeting depression
and PTSD symptoms. Elements of the treatment were provided in a stepped
fashion such that those with greater ease of delivery, for example, psycho-
education and problem solving, were given initially, followed later by more
complex elements like activity scheduling. Patient symptoms were repeatedly
measured and higher-­intensity care was initiated if the person required it.
In a later study, decision making was assisted with a technology-­enhanced
screening process (Zatzick et al., 2015) that decreased the time required in
decision making. Although the studies by Zatzick and colleagues focused
on PTSD as the only target outcome, the stepped-­care model proposed by
O’Donnell and colleagues (O’Donnell et al., 2012) aimed to address a com-
prehensive range of posttrauma psychopathology. In a two-stage screening
process, patients were screened for high-risk symptoms of PTSD, depression,
and anxiety, and treated with an evidence-­based modular CBT manual that
allowed treatment to be tailored to the patient’s individual symptom-­cluster
profiles. The Intervention with Low Effect recommendation is a reflection of
the small effect sizes associated with these interventions. This was a func-
tion of the Zatzick trials including all screened participants in their outcome
analyses (not just those who received the intervention). It could be that if the
analyses included just those who were allocated into treatment, the effects
would have been stronger. These observations are corroborated empirically
by recent meta-­analyses that systematically assess early intervention overall
population impact, an outcome assessment construct that combines both
an intervention’s treatment effect and breadth of applicability (Giummarra,
Lennox, Dali, Costa, & Gabbe, 2018).
128 Early Intervention in Adults

Intervention with Insufficient Evidence

to Recommend Recommendations
Of the remaining three treatment modalities, brief cognitive processing ther-
apy (CPT), behavioral activation, and supportive counseling received an Insuf-
ficient Evidence to Recommend recommendation. Generally, there was only one
study of these therapies, and this would have contributed to the classification.
Both behavioral activation and supportive counseling contained one study
that was compared to a wait-list control or TAU condition, whereas brief CPT
contained two studies that were compared to supportive counseling.

Comorbidity

Although PTSD is the main outcome of interest in evaluating early interven-

tion treatments for PTSD, it is also important to consider if, and how, these
treatments impacted comorbid psychopathologies. PTSD is more likely to
occur as a comorbid disorder than as a sole diagnosis (Bryant et al., 2010;
O’Donnell et al., 2016), and anxiety and depression are usually present either
as a comorbid diagnosis or at subsyndromal levels. Most studies included
measures of anxiety and depression, so the following section reviews the
impact of the treatment on anxiety and depression levels.
Of the 18 studies testing CBT-T, 16 included measures of anxiety or
depression, while the remaining two studies either did not measure these
outcomes (Shalev et al., 2012) or were unpublished (Ost, unpublished). Of
the 16 studies that measured depression, three studies found no efficacy for
CBT-T in reducing depression at posttreatment and follow-­up (Bisson et al.,
2004; Bryant, Moulds, Guthrie, & Nixon, 2003, 2005). The majority of stud-
ies (n = 8) found significant reductions in depression at posttreatment and
follow-­up (Bryant, Harvey, Dang, Sackville, & Basten, 1998; Bryant, Sackville,
Dang, Moulds, & Guthrie, 1999; Ehlers et al., 2003; Nixon, 2012; Nixon et al.,
2016; Shaw et al., 2013; van Emmerik et al., 2008; Wu, Li, & Cho, 2014), while
a small portion (n = 5) found reductions at posttreatment only (Bryant et al.,
2008; Echeburúa, de Corral, Sarasua, & Zubizarreta, 1996; Foa et al., 2006;
Freyth, Elsesser, Lohrmann, & Sartory, 2010; Sijbrandij et al., 2007). Of the
14 studies that measured anxiety, one study found no efficacy for CBT in
reducing anxiety at posttreatment and follow-­up (Bisson et al., 2004), while a
large portion of these studies (n = 6) found reductions in anxiety at posttreat-
ment but not at follow-­up (Bryant et al., 1998, 2005, 2008; Bryant, Moulds,
Guthrie, & Nixon, 2003; Echeburúa et al., 1996; Sijbrandij et al., 2007). The
majority of these studies (n = 7) found reductions in anxiety at both post-
treatment and follow-­up (Bryant et al., 1999; Ehlers et al., 2003; Foa et al.,
2006; Freyth et al., 2010; Shaw et al., 2013; van Emmerik et al., 2008; Wu et
al., 2014). Of the two studies that evaluated the efficacy of cognitive therapy,
only one study included measures of anxiety and depression, and it found
reductions in depression and anxiety at 6-month follow-­up only (Bryant et al.,
Intervention for Trauma‑Related Psychopathology 129

2008). Of the four studies that evaluated brief EMDR therapy, only one brief
EMDR study measured comorbid depressive symptoms, and it found a signif-
icant reduction in depressive symptoms at 3-month follow-­up only (­Shapiro
& Laub, 2015). The two interventions that received a classification of Inter-
vention with Emerging Evidence consisted of a structured writing intervention
(n = 2; Bugg et al., 2009; van Emmerik et al., 2008) and an Internet-­based self-
help intervention (n = 1; Cernvall, Carlbring, Ljungman, Ljungman, & von
Essen, 2015). In general, these interventions were associated with reductions
in depressive symptoms at both posttest and follow-­up periods (Bugg et al.,
2009; van Emmerik et al., 2008), and at posttest when there was no inclusion
of follow-­up assessments (Cernvall et al., 2015).
Of the 27 studies included in this review, only half showed significant
improvements in anxiety and depression symptoms. This is, in part, a func-
tion of many studies not measuring anxiety and depression, and other stud-
ies not finding a consistent effect on depression and anxiety. This is impor-
tant for clinicians to consider when treating PTSD in the first few months
following trauma exposure. Measuring depression and anxiety in addition
to PTSD symptoms as part of the initial assessment and during the course
of treatment is important in order to determine if anxiety/depression symp-
toms are shifting as a consequence of PTSD treatment.

Does “Early” Mean “Brief”?

In the aftermath of trauma, it may appear logical to assume that early inter-
vention requires a reduced treatment dose to target acute symptom presen-
tations, rather than a full treatment dose aimed at targeting enduring disor-
ders. However, a review of the duration of the intervention reveals that this
was not always the case. While a small proportion of CBT-T studies (n = 3)
implemented short treatment lengths of under 4.5 hours (Bisson et al., 2004;
Bugg et al., 2009; Freyth et al., 2010), the majority of CBT-T studies ranged
between 7.5 and 18 hours (n = 12; Bryant et al., 1998, 1999, 2005, 2008; Bry-
ant, Moulds, & Nixon, 2003; Ehlers et al., 2003; Foa et al., 2006; Nixon, 2012;
Nixon et al., 2016; Shalev et al., 2012; Sijbrandij et al., 2007; van Emmerik et
al., 2008). Cognitive therapy (n = 2) ranged from 7 to 12 hours (Ehlers et al.,
2003; Shalev et al., 2012). Only EMDR therapy demonstrated what would be
considered brief interventions ranging from 45 minutes to 3 hours (n = 4;
Jarero et al., 2011, 2015; Shapiro & Laub, 2015).
Of those interventions that were recommended as an Intervention with
Emerging Evidence, Internet-­ based guided CBT-based self-help required
participants to dedicate a total of 10 hours to work through all modules
(Cernvall et al., 2015). In comparison, structured writing therapy involved
somewhat briefer treatment doses spanning three to five sessions, with total
treatment durations as brief as 1 hour (Bugg et al., 2009) or relatively longer
at 7.5 hours (van Emmerik et al., 2008).
130 Early Intervention in Adults

The idea that early intervention could consist of a reduced dose of treat-
ment does not appear to be supported by the literature. Many of the early
treatment interventions administer a similar number of hours of interven-
tion relative to standard treatment protocols. This is because often those
individuals presenting for early intervention have a range of complexities
that increased their vulnerability to PTSD in the first place (e.g., preexisting
anxiety/depression symptoms, negative cognitive style, poor social support,
externalizing tendencies). Addressing these factors will likely increase the
time taken to achieve successful treatment outcomes.

Future Directions

Since the last treatment guidelines, early intervention has made some prog-
ress, but perhaps not as much as expected. The future lies in targeting the
different intensity of interventions to different presentations. Here, we can
use the trajectory research to help inform our thinking. It may be that the
resilience group does not require formal assistance and a universal approach
designed to offer general support is all that we should offer. We might con-
sider a low-dose/intensity intervention for those who develop subsyndromal
symptoms (on either the delayed onset or recovery trajectory) to speed up
their trajectory to recovery or prevent their transition into disorder. And
finally, we could consider full treatment for those who develop early disor-
der.
However, to do this, we need to first be able to identify the level of
risk that each trauma survivor presents with (Mouthaan, Sijbrandij, Reitsma,
Gersons, & Olff, 2014; Qi et al., 2018; Shalev et al., 2019). Some progress is
being made by pooling data from several cohorts of survivors admitted to
acute care centers (e.g., as applied in Qi et al., 2018). These studies show us
that using early PTSD symptom severity as a predictor produced remarkably
accurate estimates of follow-­up PTSD (Shalev et al., 2019). However, we are
not yet at the place where we can clearly identify which trajectory a trauma
survivor will take. It should be noted that trajectory analyses have been able
to map the distinct profiles of subgroups within a population, but we still
cannot reliabily predict in the acute phase how an individual case will fare
months later.
Longitudinal studies indicate that the mental health of trauma survi-
vors fluctuates markedly over time, and the main predictors of changing
mental health status are factors occurring in the posttrauma environment
(Bryant et al., 2013). This poses a major challenge for reliably being able to
identify people who most need early intervention. We are best at identifying
the resilience class—those who will not develop disorder. That is, most of
our screening instruments have high specificity. Screening instruments also
do a reasonably good job of identifying who currently has high symptoms,
and our trajectory plots show that the high group is likely to be the chronic
Intervention for Trauma‑Related Psychopathology 131

group. However, our screening instruments are relatively poor at identify-

ing those on other trajectories, so this is something we need to further col-
laborate on. Identifying the subsyndromal risk profiles will help us design
interventions designed to change trajectories and, it is hoped, ultimately
help prevent disorder in the long run.
With regard to predicting response to early interventions, some stud-
ies indicate that early screening for, for example, severity of acute distress,
might predict response to interventions (Frijling, 2017; Mouthaan et al.,
2013). Although progess is being made with prediction models, when it
comes to identification of risk for disorder or response to treatment, we
still have a long way to go. We also need to recognize that early intervention
studies have been limited by short-term follow-­up assessments. This issue
was highlighted in an Israeli study that found although early provision of
CBT accelerated the remission of PTSD symptoms, 3 years later the rates
of PTSD were not different from those of individuals who did not receive
early intervention (Shalev et al., 2016). Furthermore, across early interven-
tion studies, a pattern has emerged that suggests no more than two-­thirds
of people respond to recommended treatments, which highlights the need
for recognition that some people may need additional treatment beyond the
recommended early interventions for PTSD. It also highlights that we still
require the development of new early interventions so that we can compre-
hensively address poor recovery in the early aftermath of trauma.

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C H A P TE R 9

Early Pharmacological Intervention

Following Exposure
to Traumatic Events
Jonathan I. Bisson, Laurence Astill Wright,
and Marit Sijbrandij

A diagnosis of posttraumatic stress disorder (PTSD) requires a defined

external event(s), and this should, in theory, facilitate the development
of early interventions to prevent the onset of symptoms and to treat them
shortly after they emerge. Unfortunately, despite significant research effort
and major developments in our understanding of the learning and memory
mechanisms involved in processing traumatic events, we continue to search
for effective early interventions. Most early intervention research in humans
has focused on psychosocial and behavioral approaches (see O’Donnell,
Pacella, Bryant, Olff, & Forbes, Chapter 8, this volume), but there is a grow-
ing body of research concerning pharmacological approaches.
This chapter aims to help clinicians interpret the current evidence
regarding the prescription of medication in adults within the first 3 months
of traumatic events. The chapter provides advice on whether, what, when,
and how to prescribe, and discusses key considerations when prescribing
medication shortly after traumatic events.

Theoretical Context

Research has provided us with a strong understanding of the involvement of

neurotransmitters, neuropeptides, and glucocorticoids in the processing of
traumatic memories and the development and maintenance of PTSD. These

137
138 Early Intervention in Adults

include catecholamines, opioids, gamma-­aminobutyric acid (GABA), gluta-

mate, serotonin, oxytocin, and cortisol. There is also considerable evidence
that overactivity of the amygdala, driven by overactivity of the noradrenergic
system, plays a significant role and that attenuation of this should be benefi-
cial in preventing PTSD (Shin, Rauch, & Pitman, 2006).
A key aim of early pharmacological intervention work has been to
reduce adrenergic activity, either directly through drugs that work through
their effects on adrenergic receptors (e.g., propranolol) or indirectly (e.g.,
hydrocortisone) to reduce noradrenaline release. Several studies have
tried to build on our understanding of the consolidation of traumatic
memories by intervening within the so-­called golden hours, a time frame
up to 6 hours after a traumatic event occurs (Nader, 2003; Zohar et al.,
2011).
Although the data from clinical research, specifically with respect to
antiadrenergics, have not been as promising as hoped for (Sijbrandij, Klei-
boer, Bisson, Barbui, & Cuijpers, 2015), we now have a much better under-
standing of the impact of early pharmacological intervention on people at
risk of or with PTSD within 3 months of a traumatic event.

Description of Pharmacological Agents

Antiadrenergics. Propranolol, a beta-­ receptor blocker that was originally

developed to treat raised blood pressure, has been tested in a number of
randomized controlled trials (RCTs) to prevent PTSD.
Docosahexaenoic acid. Docosahexaenoic acid is an omega-3 fatty acid
found in the human body and is present in fish oil. It is widely used as a food
supplement and has been tested as an early pharmacological intervention to
prevent PTSD.
Gabapentin. Gabapentin was first developed as an antiepileptic drug.
Despite its name, it does not act via GABA neurotransmitter receptors and
is believed to act through its actions on calcium channels.
Hydrocortisone. The synthetic form of the adrenal-­gland-­produced hor-
mone cortisol has been used to try to bring about homeostasis (stability)
to the hypothalamic–­pituitary–­adrenal axis by inhibiting further release of
adrenaline and noradrenaline.
Oxytocin. Interest in this naturally occurring hormone and neuropep-
tide was sparked by knowledge of its positive impact on fear responsiveness,
stress reactivity, and social–­emotional functioning.
Selective serotonin reuptake inhibitors (SSRIs). Members of this class of
drugs (fluoxetine, paroxetine, and sertraline) are among those with the
strongest evidence of effect for treatment of PTSD present 3 months or
more after a traumatic event (see Bisson, Hoskins, & Stein, Chapter 16,
this volume). Another SSRI, escitalopram, has been subjected to one RCT
as a treatment for acute stress disorder (Suliman et al., 2015) and another
Pharmacological Intervention 139

for PTSD (Shalev et al., 2012) diagnosed within a month of a traumatic

event.

Other pharmacological agents, for example, benzodiazepines and mor-

phine, have been used in an attempt to prevent the development of PTSD,
but no studies satisfied the criteria required for inclusion in the evidence
summaries prepared for the International Society for Traumatic Stress Stud-
ies (ISTSS) guidelines.

Summary and Appraisal of the Evidence

The evidence summaries prepared for the ISTSS guidelines concerned RCTs
of pharmacological treatments used within 3 months of a traumatic event
that aimed to either prevent or treat symptoms of PTSD. Fifteen includable
RCTs were found that considered the six types of drugs described previ-
ously. Seven (47%) of the included RCTs had usable data that were included
in the primary meta-­analyses.
The overall quality of the studies included was low and there was insuf-
ficient evidence to recommend all but one of the drugs considered. Only the
meta-­analysis of the hydrocortisone RCTs showed significant superiority to
placebo, leading to it being recommended as an intervention with emerging
evidence for the prevention of PTSD in adults.
The RCTs included tended to be conducted within specific populations
who were hospital inpatients or outpatients attending the hospital as a result
of physical injury or disease. This makes it very difficult to generalize the
results to other populations. This is particularly true for hydrocortisone as
the majority of participants had septic shock or had undergone major car-
diac surgery.
As described by Bisson, Lewis, and Roberts (Chapter 6, this volume), it
is very difficult to compare the results of pharmacological treatment trials
employing placebo controls and double blinding with psychosocial interven-
tion trials using wait-list or usual-care controls and no blinding of the partici-
pant or the treating clinician. In common with other guideline development
groups (e.g., National Collaborating Centre for Mental Health, 2005), the
ISTSS Guidelines Committee determined a priori rules to allow comparison
of different types of treatment, making the threshold required for a Strong
recommendation for a drug tested through placebo-­controlled RCTs 50%
less than that for psychological treatments tested through wait-list or usual-
care RCTs. Whether the 50% lower threshold accurately reflects the true
level is open for debate, but even if the threshold had been lower, this would
not have made a difference with respect to the recommendations made for
early pharmacological interventions.
The ISTSS guideline recommendations for early pharmacological inter-
ventions are shown in Table 9.1.
140 Early Intervention in Adults

TABLE 9.1. ISTSS Recommendations for Early Pharmacological

Intervention
Intervention with Emerging Evidence—Hydrocortisone within the
first 3 months of a traumatic event has emerging evidence
of efficacy for the prevention of PTSD symptoms in adults.
Insufficient Evidence to Recommend—There is insufficient
evidence to recommend docosahexaenoic acid, escitalopram,
gabapentin, oxytocin, or propranolol within the first 3 months
of a traumatic event for the prevention or treatment of
PTSD symptoms in adults.

Quality of the Evidence

The quality of the pharmacological RCTs, assessed by the Cochrane risk of

bias tool (Higgins & Green, 2011) and modified GRADE criteria (see www.
gradeworkinggroup.org), included in the meta-­analyses was low. There were
a number of issues that indicated risk of bias in the results, especially with
respect to incomplete outcome data and the selective reporting of results.
It is also noteworthy that a number of the studies reported significant dif-
ficulty in recruiting participants (e.g., Shalev et al., 2012; Stein, Kerridge,
Dimsdale, & Hoyt, 2007), with many people refusing to participate as they
did not want to take medication.
The studies included in the meta-­analyses displayed quite significant
clinical heterogeneity, and the majority of the studies were undertaken in
higher-­income countries. These issues, in addition to the small number of
total participants and their physical health and hospital status, raise major
questions on the generalizability of these findings. This is particularly per-
tinent to people exposed to traumatic events who would not have been
included in the studies and to individuals living in settings different from
those where the research studies were conducted.

Adverse Effects

The participants reported few problematic adverse effects and the drugs con-
sidered appeared to be reasonably well tolerated in the included RCTs. That
said, an increased rate of dizziness, infection/septic shock, and raised glucose
and sodium blood levels were reported in hydrocortisone studies. Although
there was no evidence that drugs should not be considered for use because of
adverse effects, caution is clearly required, and hydrocortisone, in particular,
is associated with problematic adverse effects when taken in higher doses and
in the longer term. Hydrocortisone also suppresses the immune system, so it
may be contraindicated when there is acute infection risk.
Pharmacological Intervention 141

Practical Delivery of the Recommendations

At present, the evidence is not strong enough to recommend the routine

use of any medication to prevent or treat PTSD within 3 months of a trau-
matic event. The Intervention with Emerging Evidence recommendation for
hydrocortisone suggests the drug is a good candidate for further research in
other populations, but, at present, it cannot be argued that hydrocortisone
is ready for routine clinical use.
There will, however, be instances when individuals request medication,
for example, to help with sleep, refuse evidence-­based nonpharmacological
approaches, or present with specific troublesome symptoms (e.g., marked
insomnia or agitation) following a traumatic event. As with all treatments
for PTSD, it is vital that pharmacological treatment only be prescribed after
an accurate assessment of an individual’s needs that takes into account her
or his individual circumstances. Key issues to consider before prescribing
medication include primary diagnosis; comorbidity; alternative treatment
options; attitude toward medication; previous response to medication; fam-
ily history of response to medication; expectations of medication; awareness
of potential adverse effects; other prescribed drugs and potential interac-
tions; and other substance use and potential interactions. Medication should
only be prescribed when a clinician believes the likely benefits outweigh the
risks and when the individual is equipped with the knowledge necessary to
make a fully informed decision.

Possible Pharmacological Interventions in the First 3 Months

Prevention (Universal Intervention)
No pharmacological intervention can be recommended for routine clini-
cal use to prevent PTSD. Hydrocortisone is the only drug with emerging
evidence of benefit and requires further evaluation. In individuals with no
contraindications to its prescription, hydrocortisone could be considered as
a preventative intervention for people with severe physical illness or injury,
shortly after a traumatic event. The doses of hydrocortisone used in the
trials varied from 20 mg twice a day orally for 10 days followed by a taper-
ing period where the dose was halved every 2 days (total dose = 400 mg
over 10 days), followed by around 70 mg (exact dose not given) over 6 days
(­Delahanty et al., 2013) to a 100-mg intravenous bolus followed by tapering
over 2 days (total dose = 550 mg over 4 days; Weis et al., 2006).

Treatment of Symptoms of PTSD

If an individual with PTSD and her or his treating clinician agree that treat-
ment with medication is indicated and desired, the most logical approach,
142 Early Intervention in Adults

based on the current evidence base, would be to follow the prescribing algo-
rithm described in Bisson, Hoskins, and Stein (Chapter 16, this volume). It
should be acknowledged that no evidence exists for the efficacy of drugs to
treat PTSD within 3 months and there is evidence suggesting that escitalo-
pram is no better than placebo in preventing the development of PTSD in
individuals with acute stress disorder (ASD) or partial ASD (Suliman et al.,
2015) or for the treatment of PTSD diagnosed a month after the traumatic
event (Shalev et al., 2012).

Insomnia
Many people find insomnia a particular problem soon after a traumatic
event (Hall Brown, Ameenat, & Mellman, 2015) and ask specifically for med-
ication to help them sleep. Although there is no evidence base to support
this, if such a scenario occurs, it is recommended that the same approach
to the one for pharmacological management of insomnia in PTSD sufferers
be taken (see Chapter 16, this volume). A sedative antidepressant should be
considered first line, for example, 15 mg of mirtazapine at night (which has
the added benefit of RCT evidence supporting its use for PTSD) or 50–100
mg of trazadone at night. Both these drugs are not associated with the addic-
tive potential of drugs such as benzodiazepines or the Z drugs, and there is
some evidence of an adverse effect of early temazepam on PTSD symptoms
in one RCT that was excluded from the ISTSS evidence syntheses (Mellman,
Bustamante, Daniella, & Fins, 2002). An alternative, especially for individu-
als with significant agitation, is 25 mg of quetiapine at night. It is important
to be aware that mirtazapine, trazadone, and quetiapine can cause drowsi-
ness the following day, and other adverse effects such as weight gain, and
individuals should be warned about this.

Agitation
Agitation may be present and can be a reason for deciding to treat with
medication early on if recommended psychological approaches are not
available, have not been effective, or are not wanted. For the majority of
people with PTSD, medication for agitation is not necessary, but for some
individuals it is likely to be needed and, in addition to reducing agitation,
may also enable an individual to tolerate other treatments, for example,
psychological treatment for his or her PTSD. Given its adverse effect profile
and evidence for use for PTSD, quetiapine is recommended. Some doctors
recommend short courses of benzodiazepine for such agitation, but we do
not recommend this given the lack of evidence for benzodiazepine use, the
risk of dependency, and the risk of increased PTSD symptoms and interfer-
ence with psychological treatments through their impact on trauma pro-
cessing by impairing fear extinction (Bouton, Kenney, & Rosengard, 1990;
­Rothbaum et al., 2014).
Pharmacological Intervention 143

Future Developments

There is clearly a need to improve the evidence available for early pharma-
cological intervention following traumatic events. There is a need to develop
and test effective: (1) early universal preventative interventions, (2) indi-
cated interventions to address higher-­r isk and emerging clinical features of
traumatic stress symptomatology, and (3) treatment interventions for diag-
nosable PTSD by fully exploiting our understanding of the neurobiology
of the development and maintenance of PTSD. There are some emerging
candidates, but more research is needed to identify novel pharmacological
approaches that may help. There is a need for more clinical research with
existing drugs, for example, hydrocortisone, in different populations and
with a greater focus on dosing and duration of administration.
There is also an urgent need to ensure that our current knowledge
with regard to early pharmacological intervention is disseminated and
implemented in practice across the world. We need to strive to ensure that
people who seek treatment following traumatic events are fully informed
about evidence-­based pharmacological management so they can make an
informed decision on whether to try this approach or not.

Summary

In summary, despite some good candidate drugs, no early pharmacological

intervention can be recommended for general use within the first 3 months
of a traumatic event. There is emerging evidence that hydrocortisone may
prevent the development of PTSD, especially in seriously physically unwell
and injured populations. Despite an absence of evidence, some medications
can be considered for symptomatic relief within the first 3 months of a trau-
matic event.

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PA R T III

EARLY INTERVENTION
IN CHILDREN AND ADOLESCENTS
C H A P TE R 10

Preventative and Early Interventions

Justin Kenardy, Nancy Kassam‑Adams, and Grete Dyb

Pprevention
reventative and early interventions have the potential to reduce the ongo-
ing impact of trauma exposure. Consistent with public health models,
and early intervention to address posttraumatic stress disorder
(PTSD) in childhood can be conceptualized as primary prevention (i.e., aim-
ing to prevent the occurrence of a disease/injury), or secondary prevention
(i.e., aiming to reduce the impact of a disease/injury early on). PTSD is
unusual among mental health problems in that inception is usually clear,
and precipitants are included in the definition of the disorder. Having a
clear precipitant event or events could mean that early intervention would
be more effectively applied. However, identifying children who have expe-
rienced trauma is not always straightforward, and trauma-­related problems
may not be identified for some time. Certain types of trauma and certain
settings lend themselves to prevention and early intervention. Natural disas-
ters or war affect populations as a whole; mass violence or a school shooting
affect the community or school in which they happen. In medical settings, ill
and injured children are populations at risk because they are known to have
been exposed to potentially traumatic experiences. Other settings also see
children with known recent exposure to trauma, for example, in the United
States Child Advocacy Centers (CACs) are a widely used model for service
delivery, providing an immediate response to interpersonal traumas such as
child abuse, rape, and domestic violence.
Even when a child is identified as being at risk of PTSD following
trauma, there is no guarantee that they will receive an appropriate interven-
tion. The evidence base for preventative and early intervention after trauma
exposure in children is small and has not been widely disseminated or taken
up in clinical practice. In this chapter, we will describe the evidence on pre-
vention and early intervention evaluated by the 2019 treatment guidelines

147
148 Early Intervention in Children and Adolescents

issued by the International Society for Traumatic Stress Studies (ISTSS), as

well as practical and clinical implications for applying early interventions in
accordance with the current evidence base.

Theoretical Context

Prevention and early intervention for trauma-­exposed children have been

the focus of a number of theoretical models. Across models, key themes with
implications for practice are (1) considering levels of preventive intervention,
(2) considering time frame in relation to trauma exposure, and (3) making
use of hypothesized predictive factors and etiological mechanisms to select
appropriate targets for early intervention.
In the context of both pediatric medical trauma (Kazak, 2006) and chil-
dren exposed to disaster (Vernberg, 2002), models that frame preventative
and early interventions have applied the public health concept of three levels
of prevention: universal, targeted, and clinical/treatment. Universal inter-
ventions are directed to all children with a trauma exposure. Targeted (some-
times referred to as selective) interventions are delivered to trauma-­exposed
children with signs of acute distress and/or evident risk factors. Clinical/
treatment interventions are for trauma-­exposed children who are experienc-
ing clinically significant, persistent, and/or escalating levels of distress and
are in need of specialist psychological intervention and support. Both tar-
geted and clinical/treatment interventions require some means of identify-
ing children who need this level of intervention. Screening instruments may
be designed to detect those at risk for the development of ongoing problems
(“risk screeners”) and/or to identify those with current distress warranting
clinical attention (“concurrent screeners”). In planning early intervention,
this distinction is important, and more research is needed to develop and
validate both types of effective screening tools, and to optimize the use of
existing screening tools (e.g., timing and presentation; March et al., 2015)
Early intervention models have also delineated the evolving challenges,
adaptation, and recovery over time for trauma-­exposed children—­and the
implications of this time frame for intervention. Kazak and colleagues
(2006) and Price, Kassam-­Adams, Alderfer, Christofferson, and Kazak (2016)
described three phases for the trajectory of child and family responses to
pediatric medical trauma. In Phase I (the peritrauma period where some
aspects of the trauma may still be unfolding), the goal of interventions is
to modify the subjective experience of the potentially traumatic event by
providing trauma-­informed care or services, and to screen for risk. In Phase
II (the days to weeks after trauma exposure), intervention goals may include
screening for risk, reducing distress from emerging symptoms of traumatic
stress, and preventing the development of persistent traumatic stress. In
Phase III (months to years after trauma exposure), intervention goals are to
Preventative and Early Interventions 149

identify and treat significant ongoing traumatic stress. Based on work with
children exposed to disasters, Vernberg (2002) similarly outlined a frame-
work in which time frame (pre-, peri-, and posttrauma phases) is crucial, and
in which the appropriate use of universal, targeted/selected, and clinical/
treatment interventions is mapped onto each phase. For example, the pur-
pose of universal interventions would be distinct in each phase, focusing on
preparedness in the predisaster phase but on helping children reestablish
routines in the early postdisaster phase.
Several models have outlined risk and protective factors for the devel-
opment and persistence of traumatic stress symptoms. For example, mod-
els based on work with children exposed to disasters (La Greca, Silverman,
Vernberg, & Prinstein, 1996; Vernberg, 2002) identified the severity and
range of exposure to different aspects of the event, individual child char-
acteristics, the environment in which child recovery takes place, and the
child’s available psychological resources as key risk factors. Biopsychosocial
models (Marsac, Kassam-­Adams, Delahanty, Widaman, & Barakat, 2014)
emphasize processes across pre-, peri-, and posttrauma periods that may
contribute to PTSD development. These models point to the importance
of considering the interaction of biological factors (genetic and heritable
factors, internal physiological processes), psychological factors (memory
formation, cognitive state), and social and environmental factors (culture,
community support, parent–­child interactions). Finally, theoretical models
of specific etiological processes provide a strong basis for early interventions
that target and interrupt specific mechanisms that drive the development
of traumatic stress symptoms. To date, the most fully developed etiological
models guiding early interventions are those that highlight the role of cogni-
tive processes in the early development and maintenance of PTSD symptoms
(Meiser- ­Stedman, 2002).

Description of Models and Techniques

There are a few key characteristics of prevention/early interventions that

distinguish these from clinical treatments for children who have persist-
ing distress. The models are delivered early on following trauma, and they
tend to be briefer than the trauma-­focused therapy interventions (gener-
ally, one to six sessions). Many models include techniques grounded in CBT
approaches, but adapted for the timing and delivery mode of early interven-
tion. Across both early preventative and early treatment interventions, com-
mon clinical elements include psychoeducation about responses to trauma,
coping skills for trauma-­related distress, promotion of facing up to or expo-
sure to nondangerous cues instead of avoidance, promoting helpful cogni-
tions about the trauma, and enhancing parental support. Different models
may contain more or less of these common clinical elements.
150 Early Intervention in Children and Adolescents

Models applied in preventative or early treatment interventions are

briefly described here, with an emphasis on the core components of each
that may be included across specific intervention approaches or studies.

Trauma‑Informed Care
Trauma-­informed care for prevention and early intervention begins with
promoting recognition and awareness of trauma and its impact among
professionals across a range of service settings that commonly see children
impacted by acute or ongoing trauma, for example, schools, child protec-
tion agencies, health care settings, and law enforcement. They are educated
that potentially traumatic events are common in children’s lives, that there
is a range of impacts of trauma exposure for children, and that resilience
and recovery are common. The provision of trauma-­informed care aims to
embed this awareness in the everyday practices of these settings and to mini-
mize new potentially traumatic exposures for children and families (Marsac
et al., 2017). Thus, for example, in trauma-­informed schools, a change in a
student’s classroom behavior (becoming withdrawn or disruptive) is under-
stood through a “trauma lens.” In trauma-­informed medical settings, doc-
tors and nurses work to minimize pain and distress from medical proce-
dures. Trauma-­informed care may be appropriate at many points along the
posttrauma time frame, from the peritraumatic period onward. In the clini-
cal mental health context where children seek services, the sine qua non of
trauma-­informed care is routine screening for trauma exposure and impact.

Psychological First Aid

Psychological first aid (PFA) techniques, initially developed for postdisaster
settings, are applied universally in the very early stages following trauma
exposure. The main components are instillation of a sense of safety, promo-
tion of calming through simple skills such as slow breathing and distraction,
facilitation of self-­efficacy and empowerment, encouragement of personal
and community connectedness, and promotion of realistic hope. PFA has
been adapted for application with children in a range of settings, through
models such as Listen Protect Connect (Ramirez et al., 2013). No studies of
PFA were included in the evidence review.

Psychological Debriefing
The primary components of psychological debriefing are the narrative
reconstruction of the circumstances of the trauma to improve understand-
ing and change inaccurate interpretations of the circumstances, to pro-
mote the referencing of trauma responses to “normalize” reactions, and to
provide information about those reactions and possible additional coping
resources (Stallard et al., 2006). Psychological debriefing is distinct from
Preventative and Early Interventions 151

other very brief early interventions in its emphasis on a more active psycho-
logical processing of the traumatic event. A note of caution is in order, as the
review found emerging evidence not to recommend individual psychological
debriefing as an early preventative intervention.

Information Provision (Self‑Help)/Psychoeducation

(Self‑Directed Online)
Information provision is aimed at promoting more adaptive responses to
trauma, thereby reducing the likelihood of the development of long-term
psychopathology. The common components of effective information pro-
vision are promotion of adaptive appraisals of the potentially traumatic
events, reducing excessive and maladaptive early avoidance, and promoting
family social support (Kassam-­Adams et al., 2016). Information and psycho-
education may involve parents or caretakers as well as children, and may be
provided in person, via print materials, or via online/e-­health tools. Online
interventions offer accessible, self-­directed, and initiated interactive infor-
mation provision where the use and selection of information are within the
child’s control, possibly with facilitation by a parent, especially with children
of a younger age. Many of these interventions have been designed to be
engaging and interesting as well as pertinent to the user.

Parent Support and Training

Parent training is a component of many early intervention models, both uni-
versal self-­directed tools for parents, and in-­person interventions (targeted/
selective or treatment) that engage parents with or without their child. It
commonly includes providing parents with information about trauma and
trauma reactions and how they can assist their child in recovery based on
trauma-­informed care principles, and educating parents as to when their
child’s reactions may indicate the need to seek further help (Marsac et al.,
2013). For example, parents may be taught to help their child return to nor-
mal routines as much as possible in the posttrauma period and to inter-
pret behavior changes in the context of trauma responses. Parents are often
taught to gently support their child in facing reminders of the trauma so
that excessive avoidance does not inadvertently strengthen the development
of traumatic stress symptoms. Some early intervention models explicitly
include guided practice for parents in applying this new knowledge and set
of skills with their child.

School‑Based Training for Recovery

Schools provide a unique and well-­placed opportunity to deliver preventa-
tive care for children following trauma. Schools frequently offer continu-
ity and predictability for children and families, often have well-­established
152 Early Intervention in Children and Adolescents

relationships with children and their families, and in many cases already
deliver universal or targeted/selective interventions for a variety of social-­
emotional targets. Therefore, schools have been the setting for delivery for
many programs following traumatic events: universal programs for parents,
children, and teachers in response to a major disaster or ongoing armed
conflict to which all children will have been exposed, as well as targeted/
selective interventions that are delivered to children with identified dis-
tress (Kataoka, Langley, Wong, Baweja, & Stein, 2012). The School-­Focused
Training for Recovery program is one example (Le Brocque et al., 2017). In
this intervention, teachers are provided with in-­service training that covers
understanding possible responses to trauma, teaching practices that pro-
mote recovery, identification of children in need of further assistance, and
self-care. Schools have also been the delivery site for early interventions to
children exposed to war and violence (Berger, Pat-­Horenczyk, & Gelkopf,
2007; Karam et al., 2008; Ramirez et al., 2013; Wolmer et al., 2013).

Active Monitoring
The most likely outcome following exposure to trauma is recovery (Le
Brocque, Hendrikz, & Kenardy, 2010). However, the probability of recovery
will vary, and it is not always possible to know which children will develop
ongoing distress or problems. Therefore, a model of active monitoring (some-
times called “watchful waiting”) has been recommended as an approach that
does not interrupt natural recovery processes, and effectively utilizes scarce
resources (National Institute for Health and Care Excellence, 2018). This
approach generally includes universal initial screening for risk, paired with
ongoing monitoring for distress or symptoms to determine if targeted/selec-
tive or treatment interventions are required.

Stepped Care
Stepped care is not a specific set of techniques, but rather a model that aims
to systematically screen or monitor and to deliver the required degree of
intervention for each child at the time when needs are identified. Stepped-­
care models typically begin with less intensive modes of intervention (e.g.,
psychoeducation, active monitoring) applied universally, and then “step
up” to more intensive modes, including treatment for the child or family,
if distress does not resolve or if the child’s risk level changes (Kazak, 2006).
Stepped-­ care approaches can provide the bridge between universal, tar-
geted/selective, and clinical/treatment levels of early intervention.

Cognitive‑Behavioral Therapy with a Trauma Focus

Several variants of traditional cognitive-­behavioral therapy with a trauma
focus (CBT-T) for children (Cloitre, Karatzias, & Ford, Chapter 20, this volume)
Preventative and Early Interventions 153

have been applied as an early treatment intervention for trauma-­exposed chil-

dren. Compared to treatment of persistent traumatic stress symptoms, CBT-T
in early treatment interventions is often briefer, and techniques are frequently
adapted for context and setting of delivery (e.g., outside of traditional mental
health settings). The KidNET intervention is delivered in six sessions and cen-
ters on facilitating the creation of a life narrative, with particular attention to
any traumatic experiences (not limited to the recent acute trauma). The aim
is construction of a coherent narrative from fragmented reports, and narra-
tive exposure is employed until fear reactions subside. Catani and colleagues
(2009) implemented KidNET for war-­exposed children in refugee camps
soon after a tsunami. Even briefer CBT-T interventions have been employed
in the acute posttrauma phase, such as a two-­session intervention integrat-
ing construction of a trauma narrative, psychoeducation, and coping skills
(including exposure) that was implemented in a hospital setting for children
postaccident or burn injury (Kramer & Landolt, 2014).

Child and Family Traumatic Stress Intervention

Because parents are likely to be key to successful recovery and early interven-
tion, the Child and Family Traumatic Stress Intervention (CFTSI; Berkowitz,
Stover, & Marans, 2011) focuses primarily on enhancing the relationship
between a child and parent to promote recovery through psychoeducation,
review of results of standard measures, and coping tips. The intervention
is delivered over four sessions beginning within 30 days of the trauma and
aims to promote communication between child and caregiver/parent about
traumatic symptoms and responses, and facilitate the child and parent work-
ing together to develop adaptive coping to the traumatic stress responses,
including sleep, depressive withdrawal, behavioral problems, and intrusive
thoughts and anxiety. Depending on the specific problems of each child,
CBT-T elements are incorporated to a greater or lesser extent.

Summary of Evidence

Scoping question: “For children within the first 3 months of a traumatic event,
do psychosocial interventions, when compared to intervention as usual, waiting
list, or no intervention, result in a clinically important reduction/prevention
of symptoms, improved functioning/quality of life, presence of disorder, or
adverse effects?”
As defined here, early preventative interventions target unscreened or
minimally screened populations (i.e., any trauma-­exposed child) and aim to
reduce acute symptoms, prevent development of PTSD, and restore children
to everyday functioning. Early treatment interventions are provided to chil-
dren and their families with emerging traumatic stress symptoms and aim
to reduce the symptom levels in children with emerging PTSD symptoms or
154 Early Intervention in Children and Adolescents

clinical levels of posttraumatic stress. In this review, evidence for efficacy of

the studies interventions was defined as clinically important improvements
documented in trauma-­exposed children and adolescents.

Recommendations
Preventative Interventions
Intervention with Emerging Evidence—Self-­directed online psychoeducation for
caregivers and children.
Emerging Evidence Not to Recommend—Individual psychological debriefing.
Insufficient Evidence to Recommend—Self-­directed online psychoeducation for
caregivers only; brief CBT-T.

Early Treatment Interventions

Intervention with Emerging Evidence—Self-­directed online psychoeducation for
children.
Insufficient Evidence to Recommend—Stepped preventive care; brief CBT-T;
CBT‑T.

Appraisal of the Evidence

There are several important caveats in appraising the current evidence on

early interventions for children and adolescents. These conclusions are
based on a relatively small number of studies. Much of the evidence is pro-
vided from school-­age children and adolescents, identified in hospital set-
tings, who had been exposed to single events, limiting the generalizability of
the findings to other ages, settings, and types of trauma exposure. Follow-­up
assessments were conducted up to 6 months after intervention so that the
longer-­term impact of early interventions is not yet known.
There is a gap between fairly well-­developed theoretical models of what
children may need help with after trauma exposure and our current empiri-
cal evidence about what works for whom, and how that should be delivered.
With regard to delivery, it is notable that the empirical studies included in
this review often identified children outside of traditional mental health ser-
vice systems or online. However, the current empirically supported interven-
tions have not been implemented widely in clinical practice or in response
to population-­level trauma (i.e., postdisaster outreach programs), so we do
not know yet how these interventions would work in broad everyday practice.
Despite these caveats, these studies do provide a useful starting point to
inform early preventative and treatment interventions. In most of these stud-
ies, child participants had been highly exposed to life threat, had sustained
Preventative and Early Interventions 155

physical injuries, and were at risk of developing or had emerging PTSD

symptoms. The studies vary in the manner in which parents were engaged
or included, and encompass a range of delivery methods and intervention
settings, thus providing useful information about feasibility and practical
implementation of early intervention approaches.

Early Preventative Interventions

Self‑Directed Online Psychoeducation: Intervention
with Emerging Evidence
Online psychoeducation for children and their parents was evaluated in a
single study of injured children ages 7–16, identified in a hospital setting in
Australia (Cox, Kenardy, & Hendrikz, 2010). Self-help tools for relaxation,
coping, problem solving, pleasant events, identifying personal strengths,
and reflection on the event were provided to children and parents via a
website. The study showed promising results in helping families cope in the
early aftermath of acute trauma, perhaps being most helpful for children
with higher levels of distress (Kenardy, Cox, & Brown, 2015). As noted previ-
ously, self-­directed online interventions warrant further evaluation in larger
samples and across trauma types.

Individual Psychological Debriefing: Emerging Evidence Not

to Recommend
Two studies evaluated psychological debriefing in children exposed to road
traffic accidents and identified in hospital settings in the United Kingdom
and Switzerland. Stallard and colleagues (2006) compared debriefing to a
neutral discussion. Zehnder, Meuli, and Landolt (2010) compared debrief-
ing with usual care in a hospital. Although intervention and control groups
in each study showed a reduction in PTSD symptoms over time, the ISTSS
review found that in both studies the debriefing group experienced a smaller
reduction in PTSD symptoms at follow-­up. Psychological debriefing has been
widely used internationally. These results indicate the need for professionals
to acknowledge that we should not implement popular methods in clinical
practice when there is evidence suggesting they may be ineffective or even
slow recovery.

Psychoeducation and Brief CBT‑T: Insufficient Evidence

to Recommend
Two randomized controlled studies evaluated psychoeducation as an early
preventative intervention for children. These two small studies evaluated
children ages 7–15 exposed to acute injuries in a hospital setting (Kenardy,
Thompson, Le Brocque, & Olsson, 2008) and siblings of children diagnosed
156 Early Intervention in Children and Adolescents

with cancer (Prchal, Graf, Bergstraesser, & Landolt, 2012). Both used psy-
choeducation (information about common responses to trauma, common
course of symptoms, and coping skills to minimize reactions) via print
booklets (Kenardy et al., 2008) or psychoeducation provided in short-term
interactions (Prchal et al., 2012). Neither study found evidence for preven-
tion of PTSD symptoms. Similarly, a Web-based intervention (Marsac et al.,
2013) for parents of acutely injured children that provided psychoeducation
on promoting their children’s recovery and reducing child traumatic stress
was not effective in preventing child PTSD symptoms. The intervention
did enhance parental knowledge about child traumatic stress reactions and
adaptive coping.

Early Treatment Interventions

Self‑Directed Online Psychoeducation Interventions:
Intervention with Emerging Evidence
Even though more and more children are very active users of online and
social media platforms, very few online early interventions have been evalu-
ated. One exception is the Coping Coach intervention (Kassam-­Adams et al.,
2016) in which children interact with game characters at three different levels
to identify reactions and feelings, explore cognitive appraisals, and reduce
avoidance. The ISTSS review found emerging evidence that this technique
may reduce PTSD symptoms in recently trauma-­exposed children. Caveats
are clear—this was a single study with 72 children ages 8–12 facing acute
medical events who had some initial distress or risk factors, recruited in a
single U.S. hospital. Effectiveness of self-­directed online psychoeducation
must be explored further in larger samples and with long-term follow-­up.

CBT‑T and Brief CBT‑T: Insufficient Evidence to Recommend

CBT-T approaches do not yet have sufficient evidence overall for their effec-
tiveness as early interventions for emerging or clinical symptoms in chil-
dren. To date, very few early treatment interventions incorporating CBT-T
elements have been studied in trials that met inclusion criteria for the ISTSS
review. Two interventions delivered over four to six sessions, Narrative Expo-
sure Therapy for Children (KidNET; Catani et al., 2009) and the Child and
Family Traumatic Stress Intervention (CFTSI; Berkowitz et al., 2011), showed
reduction in PTSD symptoms. A briefer (two-­session) intervention (Kramer
& Landolt, 2014) was not effective in reducing PTSD symptoms in young
children and had some but not sufficient effect for school-­aged children.
These interventions each included CBT-T elements and were tailored to
target well-known predictors for further development of PTSD and revictim-
ization. But they vary greatly in content, training of providers (schoolteachers,
Preventative and Early Interventions 157

trained mental health professionals), intervention setting (psychiatric clinic,

refugee camp, medical hospital), nature of traumatic event, level of PTSD
risk or symptoms required for inclusion, and the timing and duration of
treatment. This heterogeneity demonstrates the flexibility needed in adapt-
ing core CBT elements for early intervention. The intervention studies have
demonstrated the feasibility of delivering CBT-T elements in diverse settings
and to diverse age groups (young children through adolescents). However,
the heterogeneity also creates challenges in taking this evidence to practice.
It is important that these and other early intervention approaches that incor-
porate CBT-T elements go on to be evaluated in additional studies and in dif-
ferent settings. As the current evidence is from studies in only two countries,
interventions may need to be tailored to cultural aspects to have the same
potential for helping children globally.

Stepped Preventative Care: Insufficient Evidence to Recommend

A single study has evaluated a stepped preventative care intervention in a
hospital setting in the United States, for injured children ages 8–17 (Kassam-­
Adams et al., 2011). The intervention did not reduce PTSD compared to
usual care. The study’s documentation of the feasibility of stepped care deliv-
ered by nurses and social workers in a hospital setting can inform ongoing
development of early interventions integrated in paediatric health care.

Practical Delivery of the Recommendations

For interventions in the early aftermath of acute trauma exposure, practical

considerations are paramount. The type of event and the recovery context
help to determine what is needed and what is feasible. Intervention models
that aim to prevent PTSD or treat early PTSD symptoms in children must
consider how, when, and where to identify children and deliver interven-
tions, the role of parents and caregivers, the roles of mental health and other
professionals, as well as developmental and cultural considerations.

Type of Event and Context of Recovery

Acute traumatic events that impact children include those (such as disasters
or mass violence) that capture public attention because these events affect
whole communities or groups of children and families at one time. Such
events may result in disruption of community and family resources that
would usually be part of a child’s support system. In addition, many millions
of children each year experience a potentially traumatic event that primar-
ily affects that child and his or her family (such as a motor-­vehicle crash,
residential fire, street violence, or a sudden medical event). The context
158 Early Intervention in Children and Adolescents

for children’s recovery is affected by the extent to which the child’s family
and community are themselves experiencing distress or disruption and the
extent to which they are able to provide support. For children in rural or
remote areas, specialized preventative services may be geographically inac-
cessible.

Where and How Are Preventative and Early Interventions

Delivered to Children?
Mental health service settings, designed for treatment-­seeking children/
families once persistent psychosocial difficulties are present, are unlikely
to be the first-line context for early psychosocial interventions. Whether the
event impacts one child and family or an entire community, in the early
aftermath it is not likely that children will show up to request mental health
services, or to be screened for their mental health needs. Whereas clinical/
treatment interventions require a trained mental health professional, univer-
sal and targeted/selective interventions can often be most feasibly delivered
in other settings and by other professionals. There is a key role for profes-
sionals who work in service systems (e.g., schools, health care, community-­
based social services) that routinely see children during and immediately
after acute traumatic events.
Mental health professionals can play an important role as consultants
for providers in other service settings. It is often useful to establish collabor-
ative agreements with other systems (e.g., Red Cross/Crescent, schools, law
enforcement, health care). Forging mutually respectful partnerships allows
mental health professionals and other service providers to learn from each
other’s expertise regarding trauma-­exposed children’s adaptation and recov-
ery across different contexts (i.e., learning and academics, physical health,
and mental health). The studies included in the evidence review reflect this
reality—­children were identified in health care settings and refugee camps
in addition to mental health agencies, and interventions were delivered by
mental health therapists or other professionals (teachers and hospital-­based
nurses and social workers), or were self-­directed by children and parents/
caretakers.

Mental Health Settings

Trained mental health professionals are needed to provide early treat-
ment interventions to address significant psychological distress after acute
trauma. In the studies reviewed here, CBT-T as well as psychoeducation
and individual psychological debriefing were delivered by mental health
professionals. Mental health providers integrated within settings such as
schools and health care facilities are well placed to respond to the needs of
recently trauma-­exposed children. But mental health professionals without
Preventative and Early Interventions 159

such formal roles can build strong relationships with these and other com-
munity settings so they are able to respond quickly when child needs are
identified.

Child Advocacy Centers

Widely available in the United States, CACs are multidisciplinary settings
that are either stand-alone or embedded in other settings (the hospital, a
prosecutors’ office). They coordinate early investigative, health, and thera-
peutic responses for children and families affected by child abuse, sexual
assault, and domestic violence. To be accredited, CACs must offer (onsite
or through standing agreements) access to both early interventions and
trauma-­specific treatment services.

Schools
Second only to parents, teachers are likely the adults with the most regular
and sustained contact with children following exposure to trauma. Teachers
can often have insight into changes in a child’s behavior and mood because
of their history and ongoing interactions with the child. Thus, teachers can
help to facilitate resilience and recovery, and can assist in identifying chil-
dren with substantial distress who are in need of targeted early intervention.
Many schools have behavioral health providers on staff or onsite. Schools
can be a venue for preventative intervention (Le Brocque et al., 2017).
Although it has been challenging to conduct RCTs, several non-RCT studies
have evaluated school-­based interventions for children recently exposed to
war or disaster, often using pre–post evaluations (Berger et al., 2007; Karam
et al., 2008; Ramirez et al., 2013; Wolmer et al., 2013). These interventions
were delivered by classroom teachers with additional training or by school
nurses or counselors.

Health Care Settings

Primary care and general practitioners have a key trusted role for many
families, emergency and hospital settings are among the first to see children
after many types of traumatic events, and medical events themselves are
potentially traumatic. Many of the existing early preventative interventions
were developed in health care settings, likely because these settings pro-
vide the opportunity to identify children soon after an exposure to trauma.
Studies included in the ISTSS evidence review commonly used health care
settings as the venue to identify trauma-­exposed children, whether the inter-
ventions were eventually delivered by mental health professionals (Berkowitz
et al., 2011; Kramer & Landolt, 2014; Prchal et al., 2012; Stallard et al., 2006;
Zehnder et al., 2010), hospital-­based staff (Kassam-­Adams et al., 2011), or as
160 Early Intervention in Children and Adolescents

self-­directed online materials (Cox et al., 2010; Kassam-­Adams et al., 2016;

Kenardy et al., 2015; Marsac et al., 2013).

Interventions Delivered Remotely or Online

Practical considerations, combined with the large number of children
exposed to acute traumatic events, have driven the development of self-­
guided interventions that are delivered via print materials or online. Several
of the studies in the review exemplify this strategy (Cox et al., 2010; Marsac
et al., 2013).

When Should Preventative and Early Interventions

Be Delivered?
One of the most debated issues in the prevention of child PTSD is the opti-
mal time frame to provide early intervention. As noted earlier, several key
theoretical models have suggested different goals for screening and inter-
vention at different times across the posttrauma recovery period.
There are several challenges to determining the optimal timing for
screening and intervention. The best (most feasible) opportunity to screen
children can be immediately following the event, when they are in the pres-
ence of health care professionals or other first responders. However, it
appears that currently available screening tools are more reliable when they
are completed at least 1 month after the event (to allow for natural recovery).
Some intervention approaches (i.e., watchful waiting, stepped care) suggest
that children be initially screened at a time close to the event, and then selec-
tively followed up and rescreened (e.g., >1 month posttrauma; March et al.,
2015). Studies included in the ISTSS evidence review initiated preventative
or treatment interventions as early as several days posttrauma, and in all but
one study interventions were initiated within 1 month posttrauma. What-
ever their results regarding effectiveness, many of these studies shed light on
the feasibility and practical implications of early screening and intervention
with children exposed to acute trauma.

Developmental Considerations in Preventative

and Early Interventions
The importance of early and preventative intervention is magnified when
viewed through a developmental lens. When trauma is experienced in
childhood, changes in psychosocial functioning can have a long-­lasting and
deeper impact on social, cognitive, and neurological development. Across
childhood, from infancy to adolescence, developmental changes and growth
add a level of complexity to the design and delivery of preventative and early
intervention. Interventions must take into account children’s differing and
Preventative and Early Interventions 161

changing needs, as well as age-­related mediating and moderating factors

that impact responses to trauma. This evidence review points out the rela-
tively small number of studies with children to date and highlights the need
for more evaluation of early preventative interventions for the youngest chil-
dren. Interventions that have been demonstrated to be effective with adults
may not necessarily work with children, and interventions that are effective
for school-­aged children may not be appropriate for preschool children or
adolescents. Furthermore, any intervention targeted for children must con-
sider the potential inclusion of parents or caregivers, and the potential need
to directly address caregiver needs.

The Role of Parents

Parents and caregivers often play a key role in facilitating resilience and
recovery following traumatic events. They do so in a number of ways. Par-
ents act to buffer their child, especially young children, from the impact of
stressors. They may achieve this by deflecting the impact of the stressor, help-
ing to reduce or eliminate the child’s direct exposure to the event, assisting
the child in responding in adaptive ways, and/or modeling more adaptive
responses to stressors. Parents’ own distress can directly or indirectly affect
their child by reducing the parents’ capacity to buffer their child’s distress
and model adaptive responses, and through changes to parenting behaviors
that lead to less adaptive and resilient behavior in their child. It is there-
fore important to consider and potentially address the health of a parent
or caregiver when delivering any preventative or early intervention for their
child. Finally, parents are often key gatekeepers for appropriate and timely
professional assistance for their child. While this is true at any age, parents
of younger children are essential for child access to services, and therefore it
is crucial to effectively engage parents in the process of intervention.
The interventions included in the ISTSS guidelines review varied in the
nature and extent of their engagement of parents, from provision of infor-
mation (Cox et al., 2010; Kenardy et al., 2008; Marsac et al., 2013) to direct
involvement of parents in the intervention as key drivers of child recovery
(Berkowitz et al., 2011). Across studies, it appears that interventions pro-
vided solely to parents were not as effective.

Ethical Considerations
Across service settings, children with recent exposure to trauma are vulner-
able to being retraumatized when the impact of these experiences is not
recognized. Thus, the provision of trauma-­informed care can be seen as a
minimal standard for providing ethical care and services (Kassam-­Adams
& Butler, 2017). Early interventions raise a number of ethical questions for
consideration; several of these are delineated next.
162 Early Intervention in Children and Adolescents

• Who will recover without intervention and how do we ensure that we do not
inadvertently interfere in natural recovery processes for a trauma-­exposed child?
What is the appropriate role for professional assistance versus promotion of “natu-
ral” helping processes in the family and community? It may go against our natu-
ral desire to provide help after trauma, but practitioners should consider
whether active early intervention is the best course of action, that is, some-
times “less is more.” Respecting and supporting the capacity of a child’s
natural support systems may be the most important first step. It is especially
important that universal interventions delivered soon after trauma “do no
harm.” Practitioners have a responsibility to consider the potential for harm
when deciding whether and how to intervene. Other ethical considerations
come into play when families actively request early intervention for a child,
for example, after serious interpersonal traumas such as sexual assault or
exposure to extreme violence or homicide. In these cases, being responsive
to family concerns by offering brief supportive psychoeducational anticipa-
tory guidance can be a way of keeping families engaged and open to other
forms of assistance should those be needed later.
• Do we have evidence to support the optimal method and timing of screening
for this child in this setting? Is there evidence to support how screening results will
guide subsequent action (i.e., immediate services vs. active monitoring vs. no fur-
ther follow-­up)? Ethical screening requires a linked pathway of care including
resourced intervention options. If screening occurs without these pathways
being available, then the process of screening will potentially contribute to
distress in the child and family without having any means to address this.

Future Developments

Future development in the area of early intervention requires attention to

the practical realities of implementation, the promise of online tools, and the
challenges of intervening after acute trauma for children already exposed to
chronic trauma. Advances in early interventions will benefit from evaluation
conducted in multiple settings by clinicians and front-line programs, and
may require adaptation of traditional randomized controlled trial designs.
It is important that interventions developed through a relatively rig-
orous empirical process be broadly applicable in practical real-world situ-
ations. That might be in a mental health setting, but for children it is more
likely to be in a school, community, or hospital setting. The field needs to
think beyond the mental health setting when considering not just the gen-
eralizability of an intervention but also its usability and sustainability. From
the outset of the development process, we should consider participatory and
user-­centered design, and end user input and validation. In the case of chil-
dren, this entails enlisting feedback not only from children but also from
parents and likely providers of the intervention.
Preventative and Early Interventions 163

Another aspect of practical delivery of early interventions is the oppor-

tunity for wider reach provided by online and e-­health tools. Children and
adolescents are prominent users of digital tools and social media. The ISTSS
evidence review points to the promise of these tools for early prevention
and treatment. Given the emerging evidence to recommend online inter-
ventions, we need continued efforts to assess Web-based interventions for
children, both self-­directed online interventions and online tools that may
complement face-to-face interventions.
The complexity of exposure to traumatic events is also a challenge
when choosing early interventions for children. Some children are exposed
to multiple types of traumatic events several times and are at higher risk
of developing psychopathology. Future development should clarify to what
degree children with chronic trauma benefit from early psychosocial inter-
ventions after an acute event.
The ISTSS review makes it clear that there is a paucity of evidence from
randomized controlled trials about which preventative and early interven-
tions work for children posttrauma. Additional key sources of information
and evidence about possible interventions include practitioners and organi-
zations operating in this space. More clinical evaluation needs to be done as
part of care, and these findings need to be available to inform development
of future interventions. Evaluations may need to think outside of traditional
RCT designs to be feasible in applied settings. However, it remains crucial
that evaluations of early interventions take into account the confounding
effects of natural remission. Finally, as our knowledge of etiological mecha-
nisms grows, this can inform both development and evaluation of new and
more effective interventions.

Summary

The two most notable findings of the ISTSS review are the emerging evi-
dence for the effectiveness of self-­directed online psychoeducation inter-
ventions as early prevention or treatment, and the caution about individual
psychological debriefing for children based on emerging evidence. Several
cross-­cutting themes emerge from this review. The current evidence sug-
gests that early preventative or treatment interventions should include chil-
dren themselves, not only engaging parents as conduits to support their
children. Interventions evaluated in this review demonstrate the need, and
the feasibility, of moving beyond the mental health setting to reach chil-
dren after trauma. Online interventions may have a key role in the “toolkit”
of early interventions for children because of their potential global reach,
accessibility, and user engagement. Finally, the ISTSS review shows that we
still lack sufficient evidence to strongly recommend specific effective early
intervention approaches for trauma-­exposed children. Given the many mil-
lions of children exposed to acute trauma each year, these findings point to
164 Early Intervention in Children and Adolescents

the need for clinicians and researchers to work together to develop effective,
practical, and sustainable early intervention approaches.

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PA R T IV

TREATMENTS FOR ADULTS

C H A P TE R 11

Psychological Treatments
Core and Common Elements of Effectiveness

Miranda Olff, Candice M. Monson, David S. Riggs,

Christopher Lee, Anke Ehlers, and David Forbes

A core component of the recent International Society for Traumatic Stress

Studies (ISTSS) guidelines for the prevention and treatment of PTSD is
a systematic review of the evidence for the psychological treatment of adults
with PTSD.
As outlined in Table 11.1, this evidence review resulted in four spe-
cific psychological treatments receiving a Strong recommendation. These
treatments, all trauma-­focused, were cognitive processing therapy (CPT),
cognitive therapy for PTSD (CT-PTSD), eye movement desensitization and
reprocessing (EMDR) therapy, and prolonged exposure (PE). Each of these
treatments has not only established a strong evidence base in its own right
but also generally demonstrated comparable outcomes in head-to-head stud-
ies with each other. As such, these treatments represent the first-line inter-
ventions in the psychological treatment of adults with PTSD. In addition to
these four specified interventions, “general undifferentiated individual CBT
with a trauma focus” also received a Strong recommendation.
The ISTSS systematic review also identified a range of other psycho-
logical interventions for which the evidence base resulted in a Standard rec-
ommendation, as well as those for which there is now emerging evidence
(see Table 11.1). Brief descriptions of all those treatments can be found
in Bisson, Lewis, and Roberts (Chapter 6, this volume), and the relevant
research data are summarized in the evidence reviews, evidence statements,
and forest plots on the ISTSS website (www.istss.org/treating-­trauma/new-istss-­
prevention- ­and-­treatment-­g uidelines.aspx). Several of those interventions are
also briefly described in other chapters of this volume. For example, guided

169
170 Treatments for Adults

TABLE 11.1. Recommendation Levels from ISTSS Guidelines for the Prevention
and Treatment of PTSD
Strong Recommendation—Cognitive processing therapy, cognitive therapy, EMDR therapy,
individual CBT with a trauma focus (undifferentiated), and prolonged exposure are
recommended for the treatment of adults with PTSD.
Standard Recommendation—CBT without a trauma focus, group CBT with a trauma focus,
guided Internet-based CBT with a trauma focus, narrative exposure therapy, and present-
centered therapy are recommended for the treatment of adults with PTSD.
Intervention with Emerging Evidence Recommendation—Couples CBT with a trauma focus,
group and individual CBT with a trauma focus, reconsolidation of traumatic memories,
single-session CBT, virtual reality therapy, and written exposure therapy have emerging
evidence of efficacy for the treatment of adults with PTSD.
Insufficient Evidence to Recommend—There is insufficient evidence to recommend
brief eclectic psychotherapy for PTSD, dialogical exposure therapy, emotional freedom
techniques, group interpersonal therapy, group stabilizing treatment, group supportive
counseling, individual psychoeducation/self-help, interpersonal psychotherapy, observed
and experimental integration, psychodynamic psychotherapy, psychoeducation, reassurance,
relaxation training, REM desensitization, supportive counseling, and trauma-focused
counseling for the treatment of adults with PTSD.

Internet-­based trauma-­focused CBT and virtual reality therapy are discussed

by Lewis and Olff (Chapter 18, this volume, on e-­mental health), while nar-
rative exposure therapy (NET) is described by Cloitre, Cohen, and Schnyder
(Chapter 23, this volume) in the context of adaptation of trauma-­focused
interventions across cultures and populations. It is noteworthy that all of the
eleven treatments assigned a Standard recommendation or Intervention with
Emerging Evidence recommendation are also trauma focused, with the excep-
tions of CBT without a trauma focus and present-­centered therapy (PCT).
The final category outlined in Table 11.1 relates to interventions for
which there was Insufficient Evidence to Recommend. To clarify, this means that
a sufficient evidence base has not been established to meet the classifications
mentioned previously. It does not necessarily imply that the interventions
listed are ineffective, but simply that a suitably robust evidence base does not
yet exist. This is, for instance, the case for brief eclectic psychotherapy for
PTSD (BEPP). Acceptance and commitment therapy (ACT), although widely
used and shown to be superior to control conditions for a range of mental
health problems (e.g., A-Tjak et al., 2015; Kelson, Rollin, Ridout, & Camp-
bell, 2019), was not included in any of the recommendation categories as no
RCTs of ACT were identified that met the inclusion criteria for the evidence
review. The RCT of ACT by Lang and colleagues (2017), while a strong study,
was excluded as it did not meet the evidence review requirement for 70% of
participants to meet criteria for a diagnosis of PTSD.
This chapter seeks to offer an overview of the four strongly recom-
mended specific treatments, reflecting on the core ingredients of each (also
Psychological Treatments 171

see Figure 11.1 for a brief overview of core ingredients), whether what they
have in common may account for their treatment effectiveness, and how
these factors may also be reflected in other interventions with (at this point)
a weaker evidence base. In addition, the chapter will consider where even
the strongly recommended interventions may struggle to achieve optimal
outcomes, highlighting future areas that still require investigation. The fol-
lowing four chapters of this volume will address each of these treatments in
turn and in detail, outlining a summary and appraisal of the evidence base
for each one, detailed guidance on the delivery of each intervention, and

CPT
Psychoeducation e
Socratic dialogue a,b,c
Cognitive worksheets a,b,c
Giving and receiving compliments d
Addressing cognitive avoidance c
Noncontingent nice things for oneselfd

CT-PTSD
Individualized case formulation a,e
Reclaiming/rebuilding your life assignments a,b,c,d
Guided discoverya,c
Behavioral experiments a,c
Updating trauma memories a,b
Discrimination training with triggers of reexperiencingd
A site visit a,b,c
A blueprint e

EMDR Therapy
Affect regulation skills e
Obtaining a suitable target b (perceptual elements, negative meaning,a
emotional response, body sensation)
Positive beliefa
Desensitization (e.g., eye movements)a,b,d
Body scan a,b
Future processing a,e

PE
Psychoeducation e
Calm breathing e
In vivo exposure a,b,c
Imaginal exposure a,b,c
Postexposure processing a

FIGURE 11.1. Core ingredients (techniques) of effective treatments. Superscript let-

ters denote mostly addressing/targeting (a) trauma-­related cognitions; (b) engaging
with, and activation of, the trauma memory; (c) experiential avoidance; (d) other;
(e) general.
172 Treatments for Adults

issues for consideration by clinicians in managing presentations where initial

attempts at delivering the treatment have resulted in suboptimal outcomes.

Core Ingredients of the Four Strongly

Recommended Effective Treatments
Cognitive Processing Therapy
The core ingredients that comprise CPT follow from the social-­cognitive
theory on which it is grounded (Resick, Monson, & Chard, 2017). This
theory holds that PTSD symptoms result from cognitions about traumatic
events not being incorporated into existing beliefs (i.e., running contrary
to preexisting beliefs) or seemingly confirming preexisting negative beliefs.
In addition, traumatic events cause significant shifts in beliefs about pres-
ent and future events. Based on this theory, creating more balanced, adap-
tive, multifaceted trauma appraisals and beliefs (both looking back on the
traumatic experience and in the present) is the primary goal of treatment.
“Psychoeducation” at the start of the intervention helps the patient to under-
stand the rationale of the therapy.
There is a predominant focus on cognitive interventions. The two
major types of cognitive interventions employed are “Socratic dialogue” and
“cognitive worksheets.” Socratic dialogue is a cornerstone practice of CPT.
It is used to help patients arrive at a different way of thinking about the
past, present, and future. It also models curiosity and critical thinking, and
encourages patients to actively engage in creating a new narrative for under-
standing their trauma and its impact. As treatment progresses, patients uti-
lize a series of cognitive worksheets to help them learn how to challenge
their unhelpful thoughts.
An additional mechanism of purported action in CPT is “identify-
ing avoidance of trauma memories and reminders,” motivating patients to
engage in the cognitive interventions designed to challenge their trauma-­
related thoughts and replace them with something more adaptive. As such,
behavioral avoidance is conceptualized as a therapy-­interfering behavior
that needs to be overcome to profit from the cognitive interventions, rather
than a specific target of the intervention per se.
Finally, two brief behavioral interventions are assigned toward the end
of the therapy: “giving and receiving compliments on a daily basis” and daily
“doing nice things for oneself.” Both of these activities are designed to fur-
ther challenge underlying trauma-­related cognitions relating to self-worth
and to help with relapse prevention regarding depression.

Cognitive Therapy for PTSD

CT-PTSD comprises eight core components, the first of which is an “individ-
ualized case formulation.” The therapist and patient collaboratively develop
Psychological Treatments 173

an individualized version of Ehlers and Clark’s (2000) model of PTSD,

which serves as the framework for therapy. This model suggests that exces-
sively negative appraisals of the trauma and/or its sequelae and disjointed
memories, which lead to easy triggering of reexperiencing by matching sen-
sory cues, lead to a sense of current internal or external threat in PTSD.
The problem is maintained by behavioral and cognitive strategies that are
intended to control the symptoms and perceived threat. Specific treatment
procedures are then tailored to this individualized formulation.
“Reclaiming/rebuilding your life assignments” are introduced from the
first session onward, designed to address the patient’s perceptions that they
have been permanently changed as a result of the trauma. These assign-
ments involve helping the patient to reclaim or rebuild previously enjoyed
and meaningful activities and social contacts.
“Changing problematic appraisals” of the trauma and its sequelae
involves guided discovery and behavioral experiments throughout treat-
ment and is closely integrated with the component of updating the memo-
ries. “Updating trauma memories” is a three-step procedure that includes:
(1) accessing memories of the worst moments during the traumatic events
and their currently threatening meanings, (2) identifying information that
updates these meanings (either information from the course of events dur-
ing the trauma or from guided discovery and testing of predictions), and (3)
linking the new meanings to the worst moments in memory.
“Discrimination training with triggers of reexperiencing” involves sys-
tematically spotting idiosyncratic triggers (often subtle sensory cues) and
learning to discriminate between “now” (cues in a new safe context) and
“then” (cue in the traumatic event). A “site visit” completes the memory
updating and trigger discrimination. Patient and therapist visit the site of
the trauma, in person or virtually (e.g., Google Streetview, recent videos or
photos) to discover how the site now looks different from the trauma and
to uncover new information that helps update the meaning and memory of
the trauma.
“Dropping unhelpful behaviors and cognitive processes” commonly
includes discussing their advantages and disadvantages, as well as use of
behavioral experiments in which the patient experiments with reducing
unhelpful strategies such as rumination, hypervigilance for threat, thought
suppression, and excessive precautions (safety behaviors).
Finally, an individualized “blueprint” summarizes what the patient has
learned in treatment and includes plans for any setbacks.

EMDR Therapy
EMDR therapy includes several key ingredients. It begins with taking a his-
tory, providing psychoeducation, and preparing the patient for EMDR mem-
ory processing. Taking a history includes assessing the principal symptoms,
such as problematic behaviors, thoughts, and feelings, as well as identifying
174 Treatments for Adults

the patient’s existing positive resources. “Affect regulation skills” may be

taught at this stage if needed (e.g., safe place imagery).
The next stage involves collaborative case conceptualization and “obtain-
ing a suitable target” for the EMDR therapy. Attention is paid to the key per-
ceptual elements of the memory (usually, an image), the negative meaning
the patient associates with this event, and the emotional response, which
includes both affect and the corresponding bodily sensation. The patient
also identifies a “positive belief,” the opposite of the negative meaning. The
choice of negative and positive meanings associated with the experience is
influenced by the patient’s history. Also, congruence needs to exist between
the meaning theme and the patient’s presenting symptoms. For example, a
patient who following a traumatic event avoids situations that might be asso-
ciated with danger is encouraged to consider a negative meaning such as “I
am not safe,” while another patient who after sexual abuse has a history of
entering into relationships where she is abused might have a theme such as
“I am bad/defective.”
The next stage of EMDR therapy focuses on “desensitization” in which
the target memory is paired with a bilateral task (typically, eye movements).
During this phase, the therapist encourages the patient to simply notice what
occurs. He or she is not continually redirected to the originally targeted
material but, rather, makes his or her own associative responses during each
set of bilateral movements. The continued focus on the target or associated
material continues until the memories become less vivid and emotional. At
this time, adaptive experiences or ideas emerge. Once the target is desensi-
tized (which is defined as a score of 0 or 1 on the Subjective Units of Distress
Scale [SUDS]), the therapist then directs patients to think about the original
incident and their identified positive belief, and to focus on that positive
belief while eye movements are continued. The aim of this is to increase and
strengthen positive associations to the original traumatic material. During
the “body scan,” the patient recalls the event and the desired positive belief
and focuses on any somatic sensations. Negative feelings are desensitized
and positive feelings are strengthened.
A final phase of the treatment is to prepare the patient for “future
processing” with the aim of protecting against relapse. Potentially difficult
future situations are identified and the therapist addresses any skill deficits
or anticipatory anxiety associated with engaging in those events. Eye move-
ments are used to desensitize such anxiety and create mastery for future
engagement.

Prolonged Exposure
PE includes several key components: psychoeducation, in vivo exposure,
imaginal exposure, and postexposure processing. Psychoeducation about
trauma, PTSD, and recovery provides foundational knowledge that helps
the patient understand the treatment and engage more fully in treatment
Psychological Treatments 175

activities. Topics include common reactions to trauma, how symptoms

develop after trauma and are maintained over time, and how PE reduces
PTSD symptoms.
In vivo exposure targets behavioral avoidance of situations, activities,
objects, or people that are objectively low risk but are avoided, because they
trigger memories and distressing emotions related to the trauma (e.g., fear,
shame, guilt). In vivo exercises are collaboratively identified by provider and
patient and are completed as homework, beginning with a moderately chal-
lenging item (one that produces some distress but the patient believes can be
completed). Assignments increase to more challenging items in successive
sessions as patients develop skill and confidence in the treatment and their
ability to manage distress. In vivo exposure reduces the intense emotion
associated with triggers and provides an opportunity to introduce and pro-
cess corrective information about safety and tolerability that, in turn, leads
to improved functioning.
Imaginal exposure blocks cognitive avoidance and facilitates processing
of the trauma memory. In imaginal exposure, the patient revisits a specific
trauma memory (typically, the trauma that the patient identifies as the most
upsetting, although in some limited instances a progressive hierarchy may
also be used here) in imagination while describing the event aloud in detail.
During imaginal exposure, the therapist actively listens to, and observes,
the patient while limiting his or her own comments to queries of subjective
distress, brief words of encouragement, or probing questions to encourage
engagement with the memory. After completion of the imaginal exposure
exercise, during the postexposure processing stage, the provider and patient
examine and process the details of the event and the emotions and thoughts
that were experienced during the trauma and during the imaginal expo-
sure session. In addition, the postimaginal processing discussion provides
an opportunity to restate and summarize the trauma memory. The provider
and patient may discuss new details or perspectives that arose, differenti-
ate the traumatic experience from other life experiences, and consider the
meaning of the traumatic event in the context of the patient’s current life.
Revisiting the event in this way promotes processing of the trauma memory
by activating the thoughts and emotions associated with the trauma in a
safe context. As such, it helps patients to realize that they can cope with
the distress associated with the memory. The imaginal exposure narrative
is recorded and the patient is instructed to listen to the recording daily
between sessions to maximize its therapeutic value.
It is worth noting that calm (controlled) breathing is also often intro-
duced in the first session as a simple means of managing distressing emo-
tions by slowing the breathing rate. It is not considered a critical part of the
protocol by most PE experts; however, because many patients find it useful,
it is typically included in the treatment. Importantly, patients are instructed
not to engage in controlled breathing while completing an exposure exer-
cise.
176 Treatments for Adults

Common Elements across These Strongly

Recommended Treatments

To summarize our understanding of which elements may be responsible for

treatment success based on the four treatments with the strongest evidence,
the core elements appear to be (1) addressing trauma-­related cognitions;
(2) engaging with, and activation of, the trauma memory; and (3) address-
ing experiential avoidance. Although all three elements are present in each
of the four strongly recommended treatments, the manner in which each of
the treatments addresses these core elements varies in emphasis, depth, and
technique.

Addressing Trauma‑Related Cognitions

It is clear from the brief descriptions outlined previously that there is signifi-
cant overlap in the focus on trauma-­related cognitions in CT-PTSD, CPT,
and EMDR therapy. It is also a key component of PE, most clearly in the
postexposure processing phase that encourages cognitive change, but cogni-
tive change also occurs through experiential learning during the exposure
exercises. The cognitive methods and techniques used to modify cognitions
might be slightly different, and the emphasis on these interventions var-
ies, but they all share the goal of achieving changes in trauma-­related cog-
nitions. It could be argued that all components of these treatments either
directly or indirectly serve to modify cognitions, but this section will focus
on those components designed to target the cognitions directly.
In CPT, the systematic use of Socratic dialogue to address problematic
trauma appraisals and a set of core themes related to current and future
beliefs, as well as more structured approaches to cognitive change, are cor-
nerstones of the approach. They are used to directly help patients arrive
at a different way of thinking about the past, present, and future. These
components model curiosity and critical thinking, encouraging patients to
actively engage in creating a new narrative for understanding their trauma
and its impact.
In CT-PTSD, the individual case formulation provides a preliminary
opportunity to modify trauma-­ related interpretations, while the updat-
ing trauma memories procedure, guided discovery and behavioral experi-
ments, and reclaiming your life assignments serve to change excessively
negative meanings that induce a sense of current threat. Guided by the
individual case formulation, key appraisals of the trauma and its sequelae
are identified and modified collaboratively. The particular cognitive tech-
niques depend on the formulation and type of appraisals. For example, for
patients who feel ashamed about the trauma, a survey is helpful to test their
predictions of what other people would think about their reactions during
the trauma.
Psychological Treatments 177

In EMDR therapy, a core element of the intervention includes the identi-

fication of key negative themes and cognitions associated with the traumatic
experience, as well as corresponding opposite positive views of the self or
the world. As the negative memories become less vivid and emotional, the
patient often spontaneously recalls other life experiences that have a positive
sense of self or the world. These are routinely tracked as they evolve over the
course of treatment. In the final stage of treatment, the patient is directed
to think of potential relapse situations and a positive sense of self, and the
therapist enhances this association.
In PE, while exposure is the core element, a second element necessary
for recovery is the introduction of information that disconfirms the expec-
tations of negative outcome associated with trauma memories. In PE, this
information is introduced experientially through the exposure exercises
themselves (e.g., experiencing distress and not “falling apart” or entering a
store and not having something bad happen). Imaginal exposure—­retelling
the trauma narrative in great detail—­a lso provides an opportunity for new
appraisals and interpretations of what happened (e.g., around perceived self-
blame). These alternative perceptions are discussed and consolidated in the
processing that occurs following the imaginal exposure. This postexposure
processing tends to be less structured and more reflective than other cog-
nitive approaches. Nevertheless, it encourages change in cognitions and is
therefore similar to more formal cognitive interventions.
A final point worthy of mention in a discussion of changing trauma-­
related conditions relates to the potential role played by psychoeducation.
It is important to emphasize that psychoeducation, despite being routinely
used in clinical practice, does not have a strong evidence base to support
its use in isolation. In conjunction with other active ingredients, however, it
may still have a role to play in helping to modify the traumatic memory. For
example, education may directly change cognitions and appraisals regard-
ing the symptomatic sequelae of trauma (e.g., “I’m losing my mind; I’m the
only person who reacts like this”) by providing a better understanding of
why the symptoms develop, their evolutionary function, and a positive prog-
nosis for treatment.
In summary, a core component common to all four strongly recom-
mended treatments is that of modifying trauma-­related cognitions whether
by assisting the patient to reevaluate and reappraise unhelpful thoughts and
beliefs through presenting alternative ideas, providing new experiences, or
reconnecting with other experiences from the past.

Engagement with and Activation of the Traumatic Memory

All four strongly recommended treatments require and include engagement
with, and activation of, the avoided traumatic memory at some level (and, in
doing so, recognize the importance of addressing experiential avoidance).
178 Treatments for Adults

In PE, the emphasis is clearly and primarily on repeated and prolonged

exposure to the cognitive, emotional, and physiological elements of the
trauma memory (imaginal exposure) and to external cues for the memory
(in vivo exposure). The theoretical foundation for PE, emotional processing
theory, posits that activation of the traumatic memory with all its constituent
elements is essential for recovery (Foa, Cahill, Smelser, & Bates, 2001). The
other three interventions all include some form of engagement with, and
activation of, the traumatic memory, although the degree of depth, dura-
tion, and repetition of this engagement varies.
In CT-PTSD, there is some imaginal reliving or narrative writing to
access hot spots in memory and update them, but these are not used as
repeated exposures. Nevertheless, it is a “trauma-­focused” approach and, as
such, requires activation of the traumatic memories to access and change
the meanings associated with the hot spots. Hence, CT-PTSD uses cogni-
tive change as a means to achieve emotional change. Similarly, CPT uti-
lizes trauma-­focused cognitive interventions, with any discussion about the
traumatic event and the associated interpretations and beliefs necessarily
constituting some form of engagement with, and activation of, the avoided
memory. More obviously, the form of CPT that includes written narratives
of the trauma account might be interpreted as an exposure paradigm even
if that is not the primary goal. A core component of EMDR therapy requires
the patient to focus on the key elements of the trauma experience, including
perceptual elements, key thoughts, and bodily sensations.
In summary, all four strongly recommended approaches are “trauma
focused” and all include direct or indirect activation of, and engagement
with, the traumatic memories.

Addressing Experiential Avoidance

The trauma-­focused work described in the previous section highlights the
issue of changing experiential avoidance of the trauma memory. However,
attention to broader experiential avoidance, including behavioral avoidance,
is also a core theme. The four strongly recommended interventions differ in
approach, but all aim to address the experiential avoidance that is so central
to the PTSD clinical picture. In PE, the in vivo exposure protocol directly
targets behavioral avoidance of situations, activities, objects, or people that
are objectively low risk, but are avoided because they trigger memories
and distressing emotions related to the trauma (e.g., fear, shame, guilt). In
CPT, avoidance of trauma reminders is explicitly identified and patients are
encouraged through cognitive interventions to engage in avoided activities.
As noted previously, in CPT the behavioral avoidance is conceptualized as a
therapy-­interfering behavior that attenuates potential gains from the cogni-
tive interventions, rather than a specific target of intervention as in in vivo
exposure, but the end result is the same. In CT-PTSD, behavioral avoidance
is addressed in several ways such as guiding patients through reclaiming or
Psychological Treatments 179

rebuilding activities and social contacts, behavioral experiments, identifying

triggers and learning to discriminate between “now” and “then” cues, and
finally through the site visit. In EMDR therapy, the experiential avoidance
is addressed in the “future processing” phase by imagining future events
that might give rise to distress, and targeting the reduction of the associated
arousal and then picturing more adaptive behaviors and ideas.
In sum, although the four treatments vary in how they target experi-
ential avoidance, including behavioral avoidance, all include strategies
designed to identify and modify this avoidance.

Putative Mechanisms

Having identified the core components that are common to the four strongly
recommended treatments, it is worth giving brief consideration to the under-
lying mechanisms: Do they work in different ways or are all three fundamen-
tally addressing the same process? A full discussion of this complex issue is
beyond the scope of this chapter, and only brief consideration will be paid
to this question here.
One theme that stands out across the core shared components is that
of activating and modifying the traumatic memory. This is achieved in dif-
ferent ways—­behavioral, affective, cognitive and somatic/physiological—­but
it could be argued that all three components involve first activating (engag-
ing with) the trauma memories and, second, incorporating new infor-
mation that is inconsistent with that contained in the existing memory.
Unhelpful, distorted appraisals and beliefs about the self, other people,
and the world are challenged and replaced by more adaptive cognitions.
This may occur via changing how the memory is stored and the new asso-
ciations made through behavioral means (e.g., in vivo exposure, behavioral
experiments, social reengagement), through affective means (e.g., imaginal
exposure and habituation, reconnecting with positive life experiences), or
through direct attempts at changing cognitions. Essentially, all fall under
an “information-­ processing” paradigm, a theoretical approach that has
long been used to explain effective treatments for the anxiety disorders in
general (e.g., Foa & Kozak, 1986) and PTSD more specifically (e.g., Foa &
Rothbaum, 1998). Critically, in addition to introducing new information to
the memory system possibly through an underlying information-­processing
paradigm, all four treatments work to reduce distress associated with the
trauma memories.
A related common mechanism appears to be that the treatments change
the personal meanings of the trauma so that it becomes less threatening to
patients’ view of themselves, the world, and their future. Empirical stud-
ies have supported the hypothesis that cognitive change drives symptom
change across a range of evidence-­based treatments for PTSD (Brown, Belli,
Asnaani, & Foa, 2019).
180 Treatments for Adults

Applicability of These Core Elements to the Other

Recommended Treatments

While CPT, CT-PTSD, EMDR therapy, and PE are the four specific treat-
ments receiving a Strong recommendation in these guidelines, undifferenti-
ated CBT with a trauma focus also received a Strong recommendation. Impor-
tantly, these undifferentiated approaches to trauma-­focused CBT routinely
include all three of the elements described previously (e.g., Bryant, Moulds,
Guthrie, Dang, & Nixon, 2003; Forbes et al., 2007). Given the central place
of those three elements in the four strongly recommended interventions,
it is not surprising that other approaches incorporating those components
would also demonstrate high effectiveness.
Similarly, the trauma-­focused treatments that received a Standard rec-
ommendation in the guidelines (i.e., a good evidence base but insufficiently
robust to justify a Strong recommendation) also tend to include these ele-
ments. Interventions such as group CBT with a trauma focus, guided Internet-­
based CBT with a trauma focus, and narrative exposure therapy all require engage-
ment with the traumatic memory, opportunities for cognitive change, and
(to varying degrees) encouragement to reduce avoidance. This argument
can be extended to many of the newer interventions (for which fewer data
are currently available) that are classified here as emerging interventions
with promise. These include interventions such as couples CBT with a trauma
focus, group and individual CBT with a trauma focus, reconsolidation of traumatic
memories, virtual reality therapy, and written exposure therapy. Thus, a large
proportion of treatments for PTSD, particularly those demonstrating high
effectiveness, utilize most or all of these three factors, applying them in dif-
ferent formats, for different populations, and in different contexts.
In this context, it is worth noting that there have been previous attempts
to identify common elements in a broader range of effective interventions
that included, in addition to the four strongly recommended treatments in
the current guidelines, interventions such as Skills Training in Affective and
Interpersonal Regulation (STAIR; Cloitre, Cohen, & Koenen, 2006) out-
lined in more detail by Cloitre, Karatzias, and Ford (Chapter 20, this vol-
ume) for the treatment of complex PTSD. The common elements identified
by those authors included psychoeducation; emotion regulation and coping
skills; imaginal exposure; and cognitive processing, restructuring, and/or
meaning making (Schnyder et al., 2015). In short, it is a very similar list to
the core elements identified previously.
It is important to emphasize that there is also a Standard recommen-
dation for non-­trauma-­focused psychological interventions such as present-­
centered therapy and group CBT without a trauma focus. It would therefore
be wrong to suggest that gains cannot be made without all of these core ele-
ments (though it is worth noting that those other approaches each include
one or more of them). Rather, the available data suggest that addressing
Psychological Treatments 181

each of these core elements to at least some degree may be central to maxi-
mizing the benefits of treatment.

Factors That Account for Treatments Not

Being Effective

The evidence is clear that, even with the most effective and strongly recom-
mended treatments, a considerable number of people with PTSD do not
respond optimally. Some show little or no demonstrable response, while
others may continue to experience significant residual symptoms and may
retain a PTSD diagnosis, even after making substantial gains. There clearly
is a need to improve this partial response or nonresponse to treatment, and
several common areas have been identified in which all four strongly recom-
mended treatments—­and, indeed, all psychological treatments—­struggle.
Certain populations do not seem to respond as well to any of our estab-
lished treatments, with often-­cited examples being military/veterans or refu-
gees (Foa et al., 2018; Monson et al., 2006; Resick, Wachen, et al., 2017; Sonne
et al., 2016) and adults with childhood onset PTSD (Karatzias et al., 2019).
The nature and breadth of comorbid conditions such as serious depression,
anger, or dissociative disorders (which are often seen in the populations
mentioned previously) may also complicate delivery of these interventions.
Anger deserves special mention, since the evidence suggests that high lev-
els of anger adversely affect symptom maintenance and treatment outcome
by preventing effective engagement with the traumatic memory—­and if the
memory is not activated, it is not available for modification (Forbes et al.,
2008; Gluck, Knefel, & Lueger-­Schuster, 2017; Lloyd et al., 2014). The pres-
ence of significant comorbidity and associated behaviors sometimes leads to
clinically motivated exclusions of patients who, for example, are currently
actively suicidal (intent with concrete plans), have an alcohol or drug depen-
dence that dominates everyday life, or are experiencing an acute psychosis.
The issue of comorbidity is addressed in more detail by Roberts, Back, Mue-
ser, and Murray (Chapter 22, this volume).
Another issue for consideration is that the patient’s primary concern
may change, highlighting the importance of collaboratively negotiating treat-
ment goals at the outset and regularly reviewing those goals—just because a
person meets criteria for a PTSD diagnosis does not necessarily mean those
symptoms are the primary concern. It may emerge in the course of therapy
that PTSD is currently not the patient’s main problem, and comorbid condi-
tions (e.g., depression, obsessive compulsive disorder, borderline personal-
ity disorder, substance use disorder, physical illness), social problems (e.g.,
debts, no stable housing, illness in the family, family distress), legal prob-
lems (e.g., custody issues, asylum), or a new negative life event (e.g., death of
a significant other) are his or her main current concern.
182 Treatments for Adults

Importantly for clinicians, although a patient’s primary concern may

shift during treatment, it is also possible (particularly in the context of the
avoidance features of PTSD) that patients may endeavor to avoid trauma
work by bringing up new or ongoing issues. Here, we note the importance of
clinicians not being too quick to leave the trauma work and thereby joining
with the patients’ avoidance. However, with attention to the potential for this
shift in patient concern to represent avoidance noted and addressed, con-
tinuing to doggedly pursue the chosen treatment in such cases where this
persists is likely to prove ineffective. While other life issues are dominating,
the person is unlikely to be able to sufficiently engage in a trauma-­focused
treatment. This may be a function not only of limited cognitive and affective
resources to devote to treatment, but also of practical difficulties. People
with other significant life concerns may find they are unable to attend ses-
sions regularly due to practical reasons or have little time or privacy to work
on their homework assignments (e.g., no stable home). Engagement in treat-
ment may also be adversely affected if patients have doubts that the treat-
ment is right for them (e.g., cultural reasons) or they are worried about the
negative consequences of others finding out about the treatment (e.g., fear
of retribution from others if they disclose details of trauma or simply the
perceived stigma of receiving mental health care). There is also considerable
debate and conflicting research evidence as to whether active compensation
claims may have the potential to interfere with treatment expectations and
efficacy (Belsher, Tiet, Garvert, & Rosen, 2012; Frueh, Grubaugh, Elhai, &
Buckley, 2007; Monson et al., 2006). Despite this conflicting research, nev-
ertheless, the impact of active compensation seeking on current needs and
treatment expectations and engagement needs to be actively considered.
Other factors that may be implicated in a more attenuated treatment
response relate to individual characteristics and circumstances. Lower pre-
treatment social support has been found to be associated with individual
trauma-­ focused therapy response (Price et al., 2018; Shnaider, Sijercic,
Wanklyn, Suvak, & Monson, 2017), and social isolation and negative social
interactions are risk factors for the onset and maintenance of PTSD (Olff,
2012; Wagner, Monson, & Hart, 2016). Personality traits such as low lev-
els of openness to new experiences have been demonstrated to reduce the
efficacy of TF-CBT (van Emmerik, Kamphuis, Noordhof, & Emmelkamp,
2011). Similarly, low readiness for change has been shown to be predictive of
reduced improvements in symptom severity over treatment and follow-­up for
veterans after PE and CPT (Cook, Simiola, Hamblen, Bernardy, & Schnurr,
2017). These factors offer a potential focus for future research.
A final major challenge of all of these intrapsychic, mostly individually
delivered interventions is their variable ability to induce broader psychoso-
cial effects on relationship functioning, work, and quality of life. In routine
clinical settings, it is clearly important to go beyond the core, evidence-­based
treatment for PTSD to assist the patient in addressing these broader issues. A
failure to do so, and to address other lifestyle issues such as physical health,
Psychological Treatments 183

is likely to mitigate against treatment gains and to increase the chances of

relapse. This issue is further addressed by Forbes, Bisson, Monson, and Ber-
liner (Chapter 26, this volume).

Discussion

The four psychological treatments that have received a Strong recommenda-

tion in the recent ISTSS systematic reviews (Bisson et al., 2019) were CPT,
CT-PTSD, EMDR therapy, and PE. Three core elements were identified that
are shared by all of these four effective psychotherapies for PTSD. These
comprise addressing trauma-­ related cognitions, addressing engagement
with and activation of the trauma memory, and addressing experiential
avoidance. As described, these elements are used in different ways across the
treatments but, by focusing on these core elements, clinicians may be better
able to remain focused and not be overwhelmed in the context of complex
clinical presentations. It is important, however, that the treatment practiced
is learned well and delivered with fidelity. Although CPT, CT-PTSD, EMDR
therapy, and PE are the four specific treatments receiving a Strong recom-
mendation in these guidelines, undifferentiated trauma-­focused CBT, which
includes all three of the elements described previously, also received a Strong
recommendation. Other trauma-­focused treatments that achieved either a
Standard or Intervention with Emerging Evidence recommendation also utilize
most or all of these three factors and apply them in different formats, for dif-
ferent populations, and in different contexts. A greater focus on the common
elements across effective PTSD treatments may assist clinicians in delivering
the best interventions to their patients and in managing complex cases.
Roberts and colleagues (Chapter 22, this volume) outline approaches
to addressing comorbidity in more detail. At this point, it is worth noting
the potential for improved outcomes by formalizing (e.g., through manuals,
treatment guidelines, and training) how to manage and incorporate comor-
bid conditions (e.g., substance dependence; personality disorders; self-­injury)
into the recommended interventions to enhance outcomes. For example, if
a person with PTSD is misusing substances in CPT, improvements can be
made in training providers on how to target cognitions that are specific to
substance use to address misuse that is also conceptually linked to avoid-
ance that maintains PTSD. The broader issues of dissemination, training,
and implementation are addressed in more detail by Riggs and colleagues
(Chapter 24, this volume).
Four treatments are effective, but there are limitations. Should we pro-
vide greater session frequency or more intensive treatment formats? There
is some indication of effectiveness here in populations with more chronic or
complex PTSD (Ehlers et al., 2014; Mendez, Nijdam, ter Heide, van der Aa,
& Olff, 2018; van Woudenberg et al., 2018). Another limitation in our sci-
ence is to know which people with PTSD benefit more from which particular
184 Treatments for Adults

treatment approach. Personalized medicine is still in its infancy; we still do

not know what works for whom. Should we target the ingredients to those
that best match the person with PTSD? Should we stick to different interven-
tions but better target the type of intervention to the person with PTSD?
Can we tailor the intervention to the needs of different patient groups (e.g.,
age, sex, culture, comorbidities, type of trauma, illness duration, severity)?
These, however, remain open questions and are addressed in more detail
by Cloitre and colleagues and Forbes and colleagues (Chapters 23 and 26,
respectively, this volume).
As long as we do not have firm evidence for these tailored interventions,
the biggest gain will be reached with optimal training in at least one of the
four psychotherapies that we know work best. This training should include
supervision/consultation in the treatment procedures by someone trained
in the therapy protocol, as such consultation has been shown to improve
patient-­level PTSD outcomes (Monson et al., 2018). Moreover, practicing
with fidelity to whichever treatments are offered is important to treatment
outcomes (e.g., Farmer, Mitchell, Parker-­Guilbert, & Galovski, 2017; Holder,
Holliday, Williams, Mullen, & Suris, 2018; Maxfield & Hyer, 2002).
The best-case scenario is for clinicians to learn more than one evidence-­
based therapy (EBT) to fidelity (i.e., having more than one tool in the tool-
box). This will allow a clinician to offer different treatments to different
patients based on patient characteristics such as patient preference in the
choice of treatment. This is potentially important given data indicating that
patient preference is a significant predictor of treatment response in PTSD
(Zoellner, Roy-Byrne, Mavissakalian, & Feeny, 2019) and other mental health
conditions (see Swift & Callahan, 2009, for meta-­analysis).
Each of these treatments, as outlined earlier, while sharing common
elements and possibly a core unifying underlying mechanism of action, var-
ies in its focus, depth, and technique. As such, being able to offer differ-
ent treatment options for consideration will benefit the patient—­particularly
when one approach has not resulted in optimal outcomes. The option to
consider another variant approach that may better suit the patient has the
potential to enhance outcomes, with empirical studies needed to test the
added effects of offering a second intervention. Future research on individu-
alized effective ingredients in combination with clinicians’ experience with
different types of treatment will ultimately bring the best treatment to the
patient. The issues of future directions in treatment and personalized medi-
cine are addressed in more detail by Cloitre and colleagues and Forbes and
colleagues (Chapters 23 and 26, respectively, this volume).

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C H A P TE R 12

Prolonged Exposure
David S. Riggs, Larissa Tate, Kelly Chrestman, and Edna B. Foa

O riginally developed by Edna Foa and colleagues (Foa, Hembree, &

Rothbaum, 2007; Foa, Rothbaum, Riggs, & Murdock, 1991), prolonged
exposure (PE) is a manualized treatment for posttraumatic stress disorder
(PTSD) with decades of research supporting its efficacy (for reviews, see
Cusack et al., 2016; Kline, Cooper, Rytwinski, & Feeny, 2018; Lenz, Hak-
tanir, & Callender, 2017; Powers, Halpern, Ferenschak, Gillihan, & Foa,
2010; Watts et al., 2013). In the current Posttraumatic Stress Disorder Preven-
tion and Treatment Guidelines published by the International Society for Trau-
matic Stress Studies (ISTSS; www.istss.org/getattachment/Treating-­Trauma/
New-ISTSS-­Prevention-­and-­Treatment- ­G uidelines/ISTSS_PreventionTreatment-
Guidelines_FNL.pdf.aspx), PE received a Strong recommendation for the
treatment of PTSD. PE has also received similarly strong recommendations
in other recent clinical practice/treatment guidelines (e.g., American Psy-
chological Association, 2017; Department of Veterans Affairs & Department
of Defense, 2017; National Institute of Health and Care Excellence, 2018;
Phoenix Australia—­Centre for Posttraumatic Mental Health, 2013). In the
following pages, we describe the theoretical foundations of PE and discuss
the specific techniques of this therapy. Additionally, we provide a brief over-
view of the evidence for the efficacy of PE as part of the ISTSS guidelines
review. The balance of the chapter consists of a discussion about practical
considerations in the delivery of PE and suggestions for future directions in
the refinement of PE.

Theoretical Foundations

The theoretical foundations of PE are rooted in the emotional process-

ing theory of fear first applied to anxiety disorders and their treatment by

188
Prolonged Exposure 189

Foa and Kozak (1986) and later expanded into a comprehensive theory on
the effects of trauma, natural recovery from trauma, and the efficacy of
cognitive-­behavioral approaches to treating PTSD (e.g., Foa & Cahill, 2001;
Foa, Huppert, & Cahill, 2006; Foa & Riggs, 1993). Emotional processing the-
ory proposed that emotions are represented as cognitive-­memory structures
that include representations of stimuli, responses, and meaning associated
with the particular emotion. The original formulation of emotional process-
ing theory focused on the emotion of fear; later discussions, particularly in
the context of trauma, extrapolated the model to encompass other emotions
that commonly accompany traumatic events, such as horror, disgust, anger,
guilt, and shame (Harned, Ruork, Liu, & Tkachuck, 2015; Held, Klassen,
Brennan, & Zalta, 2018).
These cognitive-­emotion networks become “active” and the emotion is
experienced when a sufficient number of stimuli and response representa-
tions are activated. Foa and Kozak (1986) suggested that these networks (spe-
cifically, the fear network) become pathological when there are erroneous
associations among the representations in the network. For example, if the
representation of a housecat (or any other typically benign object) is errone-
ously associated with the meaning “threat,” then a person would experience
feelings of fear when the “cat” representation is activated by environmental
cues. It is also possible for the cognitive-­emotion networks to be pathologi-
cal when the response representations produce extremely high arousal when
activated (Foa & Kozak, 1986). For instance, many a person has employed
the “5-second rule” to eat a cookie that has fallen to the floor; others have
very intense feelings of disgust at just the thought of eating something that
has touched the floor, so much so that actually eating the cookie would be
practically impossible.
In the case of PTSD, it is thought that the traumatic experience results
in a specific cognitive emotional memory structure that incorporates stimuli
and the varied emotional responses present at the time of the trauma. It is
further proposed that this trauma memory structure includes (1) a large
number of stimulus elements associated with the emotion networks such as
fear, horror, guilt, or sadness; (2) representations of the physiological/emo-
tional/behavioral responses that engender intense arousal; and (3) associa-
tions between response representation and the meaning of self-­incompetence
(Foa et al., 2007). Modification of the pathological network requires the acti-
vation of the trauma memory structure and the introduction of new informa-
tion that is incompatible with the erroneous information included therein
(Foa & Kozak 1986; Foa et al., 2007). Avoidance interferes with this process
by limiting activation of the trauma memory structure and the opportunities
for corrective information to be introduced. PE accomplishes the conditions
needed for modification by actively working to overcome avoidance through
having the client systematically confront stimuli that create distress and are
avoided despite having a low probability of resulting in harm. These stimuli
include situations that the person has been avoiding (e.g., crowds, driving,
190 Treatments for Adults

specific locations) and the memories and images associated with trauma.
Confronting these stimuli activates the trauma memory structure (and asso-
ciated emotional structures), rendering new information about the stimuli
(e.g., the feared consequence did not occur) and about one’s reactions (e.g., I
did not “go crazy”) that can be incorporated into the network.

Description of Techniques

As suggested by its name, PE promotes the confrontation of distressing

stimuli through intentional exposure to these stimuli (Foa et al., 2007). Indi-
viduals with PTSD tend to avoid two broad classes of stimuli: external (i.e.,
objects, places, situations) and internal (i.e., memories, images, emotions,
physiological arousal). Therefore, PE utilizes two forms of exposure exer-
cises, including in vivo exposures to the external stimuli and imaginal expo-
sure to encourage the activation and processing of the traumatic memory.
These techniques, along with other components of PE, are described previ-
ously. This discussion highlights the exposure components of PE; it should
be noted that other elements of the protocol (i.e., psychoeducation and
relaxed breathing) are introduced earlier in the protocol (i.e., in Sessions 1
and 2) than are the exposure exercises, which are initiated after Session 2 (in
vivo) and in Session 3 (imaginal).

Components of PE
PE is a manualized protocol that includes several key components, all of
which are introduced relatively early in treatment.

In vivo Exposure
In vivo exposure targets behavioral avoidance of situations, activities, objects,
or people that are objectively low risk, but are avoided because they trigger
memories and distressing emotions related to the trauma (e.g., fear, shame,
guilt). Specific in vivo activities are collaboratively identified by the provider
and client and ranked from least to most distressing. Activities are assigned
systematically throughout the rest of treatment, starting with less distressing
situations and gradually taking on more difficult situations as the individual
develops skill and confidence in the treatment, and in his or her own ability
to manage distress. In vivo assignments are typically completed by the client
as homework assignments between sessions and are repeated over several
days or weeks until they no longer trigger excessive distress and avoidance.
In vivo exercises generally begin with a moderately challenging item (one
that produces some distress but the patient believes can be completed) and
then “steps” up to more challenging items in successive sessions. As part of
each session, the in vivo exposure homework from the preceding session is
Prolonged Exposure 191

reviewed and new assignments are selected. In vivo exposures reduce intense
emotion associated with triggers and introduce corrective information about
safety and tolerability that leads to improved functioning.

Imaginal Exposure
Imaginal exposure blocks cognitive avoidance and facilitates processing
of the trauma memory. In imaginal exposure, the client repeatedly revis-
its a specific trauma memory (the standard is to use the memory of the
trauma that the client identifies as the most upsetting) in imagination while
describing the event aloud in detail. The narrative of the memory is typically
repeated for approximately 40–45 minutes. During the imaginal exposure
session, the therapist is actively engaged in listening to and observing the
client. The clinician does not engage in conversation or discussion of the
traumatic memory, but rather limits his or her comments to queries of sub-
jective distress, brief words of encouragement, or probe questions designed
to encourage engagement with the memory. After the completion of the
imaginal exposure exercise, the provider and client review and process the
details of the event and the emotions and thoughts that were experienced
during the trauma and during the imaginal exposure session. Revisiting the
event in this way promotes processing of the trauma memory by activating
the thoughts and emotions associated with the trauma in a safe context.
Imaginal exposure also helps clients realize they can cope with the distress
associated with the memory. The imaginal exposure narrative is recorded,
and the client is instructed to listen to the recording daily between sessions
to maximize its therapeutic value.
The postimaginal exposure processing discussion may in some ways
appear similar to more formal cognitive interventions; in contrast, it is gen-
erally informal, supportive, and reflective. The discussion follows the experi-
ences reported by the client and serves to restate and summarize both the
trauma memory and the thoughts and emotions that arose during exposure.
During processing, the provider and client may discuss additional details
or new perspectives that arose, differentiate the traumatic experience from
other life experiences that may trigger similar emotions but are not danger-
ous in the way the trauma was, and consider the meaning of the traumatic
event in the context of the client’s current life and future goals. Although
formal cognitive interventions are not standard in PE processing, it has not
been found to hinder the therapeutic outcome when used in conjunction
with imaginal exposure (Foa et al., 2005). It has been suggested that some
clients, principally those who lack basic emotion regulation skills, may ben-
efit from a more structured approach, such as the addition of emotion reg-
ulation skills training that is included in dialectical behavior therapy (M.
Harned, personal communication, May 22, 2019). Generally, however, the
added effort on the part of client and provider has not been shown to result
in additional therapeutic gain in most PTSD clients.
192 Treatments for Adults

Psychoeducation
Psychoeducation about trauma, PTSD, and recovery provides foundational
knowledge that helps the patient understand the treatment and engage more
fully in treatment activities. Most of the educational material in PE is deliv-
ered in the first three sessions, but topics may be revisited throughout treat-
ment, as needed, to reinforce learning. Topics include common reactions
to trauma, how symptoms develop after trauma and are maintained over
time through processes such as avoidance and cognitive errors, and how the
treatment reduces PTSD symptoms by targeting these maintaining factors.

Relaxed Breathing
Relaxed breathing is an optional component of PE and is typically intro-
duced in the first session as a simple means of managing distressing emo-
tions by slowing the breathing rate. It is not considered a critical part of the
protocol by most PE experts; however, many clients have found it useful and
so relaxed breathing is typically included in the treatment. Importantly, cli-
ents should be instructed not to engage in controlled breathing while com-
pleting an exposure exercise. Although adverse reactions to relaxed breath-
ing are not noted in the literature, in our clinical experience there are some
clients for whom the controlled breathing can serve as a trauma reminder.
For example, medics and corpsmen are often taught to control their breath-
ing when treating a wounded service member on the battlefield. In some
cases, this controlled breathing can become associated with the trauma of
the injury (or death) of the service member and similar breathing may cue
the trauma memory. In these cases, omitting the relaxed breathing training
from PE is recommended. However, it may be useful to include such breath-
ing on the list of in vivo exposure exercises.

Summary and Appraisal of the Evidence

The ISTSS Guidelines Revision Committee conducted meta-­ analyses of

PTSD symptoms posttreatment, answering various scoping questions posed
a priori (as outlined by Bisson, Lewis, & Roberts, Chapter 6, this volume).
The Committee included PE in these analyses and specifically reported on
how PE compared to wait list or treatment as usual (TAU), interpersonal psy-
chotherapy (IPT; Markowitz et al., 2015), and metacognitive therapy (MCT;
Wells, Walton, Lovell, & Proctor, 2015). Overall, the results prompted the
Committee to make a strong recommendation for PE in the treatment of
PTSD in adults. Specifically, PE was found to be more effective in reducing
PTSD symptoms than no treatment with consistently large effect sizes.
Research has demonstrated the effectiveness of PE across a variety of
populations (Cahill, Rothbaum, Resick, & Follette, 2009), including military
Prolonged Exposure 193

veterans (e.g., Cooper & Clum, 1989; Goodson, Lefkowitz, Helstrom, &
Gawrysiak, 2013; Schnurr et al., 2007; Tuerk et al., 2011) and active duty pop-
ulations (e.g., Blount, Cigrang, Foa, Ford, & Peterson, 2014; Foa, McLean, et
al., 2018). PE has also been shown to be effective in the treatment of PTSD
in victims of physical and sexual assault (e.g., Foa et al., 1999, 2005; Resick,
Nishith, Weaver, Astin, & Feuer, 2002; Resick, Williams, Suvak, Monson, &
Gradus, 2012), motor vehicle accidents (e.g., Blanchard et al., 2003), and
mixed traumas (e.g., Bryant et al., 2008). Importantly, evidence supporting
the effectiveness of PE for PTSD has emerged from research centers around
the world.

PE versus Wait List or TAU

In the review conducted by the ISTSS Guidelines Revision Committee, a
total of 12 studies were included that examined the effectiveness of PE in
reducing PTSD symptoms versus a wait-list or TAU control group. Overall,
PE showed a positive effect when compared to these groups and was more
effective in treating PTSD than wait list or TAU. These results were demon-
strated across a variety of populations, including sexual assault victims (e.g.,
Foa et al., 1991, 1999; Resick et al., 2002; Rothbaum, Astin, & Marsteller,
2005), other assault or abuse victims (e.g., Foa et al., 2005), non-­Western
patients (e.g., Asukai, Saito, Tsuruta, Kisimoto, & Nshikawa, 2010), veter-
ans (e.g., Nacasch et al., 2011), and active duty service members (e.g., Foa,
McLean, et al., 2018; Reger et al., 2016).

Limitations
Several limitations to these studies should be discussed. First, a few of these
studies had relatively small sample sizes (e.g., Asukai et al., 2010; Foa et al.,
1991; Nacasch et al., 2011; Wells et al., 2015), which makes it difficult to gen-
eralize the findings to the larger population of patients with PTSD. Second,
some additional potential biases must be noted, as highlighted by the meta-­
analyses conducted by the ISTSS Guidelines Revision Committee. For exam-
ple, there was a high risk of bias due to incomplete outcome data or attrition
(e.g., Foa et al., 1991; Rothbaum et al., 2005; Wells et al., 2015), lack of blind-
ing of outcome assessment or detection bias (e.g., Wells et al., 2015), and other
reasons (e.g., Asukai et al., 2010; Foa et al., 1991, 1999; Nacasch et al., 2011;
Resick et al., 2002; Wells et al., 2015). Additionally, there was an unclear risk
for bias in regard to random sequence generation (e.g., Foa et al., 1991, 1999;
Resick et al., 2002; Rothbaum et al., 2005), allocation concealment (e.g., Foa
et al., 1991, 1999; Fonzo et al., 2017; Nacasch et al., 2011; Pacella et al., 2012;
Resick et al., 2002; Rothbaum et al., 2005), blinding of outcome assessment
or detection bias (e.g., Fonzo et al., 2017), and selective reporting bias (e.g.,
Asukai et al., 2010; Foa et al., 1991, 1999, 2005; Pacella et al., 2012; Reger et
al., 2016; Resick et al., 2002; Rothbaum et al., 2005; Wells et al., 2015).
194 Treatments for Adults

PE versus IPT
To date, only one RCT has been conducted examining the efficacy of PE
compared with IPT (Markowitz et al., 2015). The researchers also included
relaxation therapy (RT) as an active control condition. At random, 110 eli-
gible participants were assigned to one of the three conditions. All three
groups showed improvement in clinician-­rated PTSD symptoms, and the PE
and IPT groups did not differ in the amount of symptom improvement.
However, only the PE group showed a reduction in PTSD symptoms signifi-
cantly greater than the RT group.

Limitations
One of the major limitations of determining the efficacy of IPT in treating
PTSD versus PE is that only one empirical study has been conducted com-
paring the two treatments. Additionally, meta-­analyses determined a high
risk for other biases in the Markowitz and colleagues (2015) study. Currently,
PE cannot be determined to be a superior treatment to IPT.

PE versus MCT
Only one RCT has been conducted comparing the efficacy of PE to MCT.
MCT is a therapy that focuses on changing how one responds to negative
thoughts and beliefs, rather than changing thought content. In the previ-
ously mentioned study by Wells and colleagues (2015), MCT showed a supe-
rior effect in self-­reported PTSD symptoms compared with PE, and MCT
resulted in these improvements more rapidly than PE.

Limitations
Although the results of the aforementioned study demonstrated the success
of MCT, there has only been one study conducted examining the compari-
son of this therapy to PE. Additionally, the sample size was relatively small
and the study contained several potential risks for biases, including a high
risk for incomplete outcome data or attrition, high risk for blinding of out-
come assessment or detection bias, high risk for other biases, and an unclear
risk for selective reporting or reporting bias.

Practical Delivery of PE

In its standard form, PE is delivered in a series of 90-minute outpatient ses-

sions typically held once or twice per week. Studies included in the review
that formed the foundation of the ISTSS treatment guidelines revision rec-
ommendation provided 9–12 sessions of PE. Practically, though, clients may
Prolonged Exposure 195

demonstrate significant improvement in fewer than nine sessions and others

may require more than 12 sessions. We currently recommend that clinicians
plan to provide 8–15 sessions of PE for their clients with PTSD. Each PE ses-
sion is structured much as other cognitive-­behavioral treatment sessions are,
beginning with a review of homework (after the first session), continuing
through specified exercises, and ending with the assignment of homework
exercises to be completed prior to the next session.
PE is a fairly structured treatment, with aspects of the protocol intro-
duced sequentially across the first several sessions. The first session is largely
dedicated to psychoeducation around issues related to trauma, the develop-
ment and maintenance of PTSD, and an overview of PE procedures. The
second session continues psychoeducation, with a focus on conveying the
common reactions to trauma and their relation to PTSD symptoms. This
session also includes introduction of in vivo exposure and development of
a hierarchy to guide the in vivo exposure exercises. The initial in vivo expo-
sure exercises are assigned as homework at the end of this session. In Ses-
sion 3, the procedures for imaginal exposure are introduced and the initial
imaginal exposure exercise is completed. The imaginal exposure exercise in
this and all ensuing sessions is audiorecorded to allow the client to review it
daily between sessions as homework. The balance of sessions introduce more
challenging in vivo homework exercises and continue the imaginal exposure
exercises in session. In the final session, the therapist and client review the
progress made through treatment, develop a plan to prevent relapse, and
explore the patient’s feelings related to the end of treatment.
Although the basic structure of many of the PE sessions is similar, cli-
nicians will likely find that each session takes on different characteristics.
For example, in early sessions, therapists are likely to find themselves in the
role of “coach,” encouraging clients to try to overcome their tendency to
avoid upsetting memories or emotions. Portions of these early sessions may
also be devoted to discussing resistance to homework exercises or trouble-
shooting exercises that have not been successful. In later sessions, as clients
begin to gain confidence and overcome anxiety, therapists may find them-
selves largely serving as “consultants,” providing guidance as clients select
and plan the exercises to be completed that week. Clinicians will also likely
notice that the trauma narrative changes as sessions proceed, one reason
that it is important to record each imaginal exposure session. Clients will
add or drop specific details from the narrative, often with each repetition,
but the nature of the narrative may also change. Our clinical experience
suggests that the narrative tends to gain a greater coherence and temporal
order with repetitions. Such changes in content and structure may serve as
discussion points in the processing of the imaginal exposure exercises.
Despite the overall structure of the PE protocol, there is a great deal of
flexibility that allows clinicians to individualize the treatment to address the
needs of specific clients. Some of this is built into the protocol itself. Thus,
the specific items included on the in vivo hierarchy will reflect the avoidance
196 Treatments for Adults

behavior of each individual client. Similarly, each client will relate the events
of his or her own trauma during imaginal exposure exercises. Beyond this,
though, clinicians will work with each client to plan which in vivo items to
use for exercises and how rapidly to proceed through the exercises. Imaginal
exposure, too, can be modulated to meet clients’ needs. These and other
modifications to the PE protocol are discussed below.

Challenges to Delivery of PE
There can be a number of challenges to the delivery of PE, including very
practical issues pertaining to the delivery of sessions, resistance from clients,
and reticence on the part of clinicians. The practical barriers to PE delivery
that we most commonly encounter include having to schedule 90-minute ses-
sions, logistic barriers to holding regular weekly sessions, and the require-
ments to record sessions for use in homework assignments. Some clients are
resistant to engaging in PE because it requires them to confront memories
and situations that are distressing. Clinicians, too, can be resistant to engag-
ing in PE because we do not want our clients to be upset, or exacerbate the
patient’s symptoms, or because we do not want to become upset ourselves
as we listen to clients describe their traumas. Clinicians may also be reticent
to engage a client in PE because this approach to therapy is different from
treatment with which they are more familiar. Fortunately, the many years of
experience using PE in a variety of settings, as well as a number of recent
research efforts, provide guidance on how to address these challenges.

Modifications of PE and Strategies to Address

Logistical Challenges
One key barrier to the adoption of PE is the requirement to schedule 90-min-
ute treatment sessions. As a result, clinicians sometimes shorten sessions to
60 minutes in duration. Clinical experience suggests that this can often be
accomplished with little or no detriment in outcome, particularly with later
sessions where the imaginal exposure exercise may take only 30 minutes to
complete (Foa et al., 2007). In addition, in the U.S. Veterans Affairs health
care system, for example, the second session is commonly divided into two
separate sessions: one focused on education about common reactions and
another introducing in vivo exposure. Some recent research also supports
the efficacy of PE delivered in 60-minute sessions. Nacasch and colleagues
(2015) found that 60-minute PE sessions that included at least 20 minutes of
imaginal exposure were noninferior to the standard 90-minute sessions that
include 40 minutes of imaginal exposure. Similar results were found by van
Minnen and Foa (2006) in an uncontrolled trial. A third study (Foa, Zand-
berg, et al., 2018) is currently under way to replicate these findings with U.S.
military personnel and a sample large enough to provide adequate power to
test the noninferiority between 60- and 90-minute sessions.
Prolonged Exposure 197

There are sometimes logistical issues related to recording sessions for

use in imaginal homework exercises. One solution to this is the development
of smartphone applications such as the PE Coach app developed by the U.S.
Departments of Veterans Affairs and Defense. This application is installed
on the client’s smartphone and includes a range of capabilities to support
PE, including the ability to record sessions for later playback. In addition, PE
Coach includes the ability to construct the in vivo hierarchy, track homework
completion, and monitor symptom severity over time (Reger et al., 2013).
Initial studies demonstrate client and therapist interest in using smartphone
applications as part of therapy for PTSD (e.g., Erbes et al., 2014; Reger,
Skopp, Edwards-­Stewart, & Lemus, 2017).
Another logistical challenge that may arise is clients finding it difficult
to attend weekly (or biweekly) therapy sessions. Recent advances in the use
of tele-­health offer a method for addressing these logistical challenges in
PE delivery. Tuerk, Yoder, Ruggerio, Gros, and Acierno (2010) conducted
an uncontrolled study in which 12 veterans with combat-­related PTSD were
treated with PE delivered via telephone therapy sessions. These veterans
experienced statistically significant decreases in PTSD symptoms, with effect
sizes on a par with those veterans that receive standard in-­person PE. Addi-
tional controlled studies support the efficacy of PE delivered via tele-­health.
In one study, participants in both a home-based tele-­health group and an
in-­person PE group experienced significant reductions in clinician-­rated
symptoms of PTSD, depression, and anxiety (Yuen et al., 2015). Further-
more, tele-­health PE was found noninferior to the in-­person PE at the end
of treatment. Another RCT found home-based tele-­health PE noninferior
to in-­person PE with regard to reducing PTSD. Reductions in PTSD in both
groups were maintained at 3- and 6-month follow-­ups (Acierno et al., 2017).

Clinician Concerns about Using PE

Despite years of research supporting PE’s effectiveness in treating PTSD,
many clinicians still do not utilize it. One most often-cited reason by clini-
cians is concern the treatment could cause patient decompensation (Becker,
Zayfert, & Anderson, 2004; van Minnen, Hendriks, & Olff, 2010), despite
research demonstrating that this is an extremely unlikely outcome with PE
(Jayawickreme et al., 2014). Ruzek and colleagues (2016) surveyed nearly
1,300 U.S. mental health clinicians serving veterans enrolled in a national
Veterans Affairs PE training program. Prior to training, these clinicians
were interested in and had positive expectations about PE, but were con-
cerned the treatment might increase patient distress and worsen symptoms.
The studies reviewed for the ISTSS guidelines revision indicated that
PE is both effective and safe for treating PTSD. Despite the fact that PE is a
safe procedure, it is possible that some clients will become so distressed dur-
ing exposure exercises, particularly imaginal exposure exercises, that they
are unable to integrate new information into the trauma memory network.
198 Treatments for Adults

Indeed, the protocol recognizes this and builds in strategies for what is
termed patient over­engagement with the trauma memory (Foa et al., 2007).
It is important to note that overengagement does not mean the client has
become emotional or upset. Rather, overengagement is defined by a level of
emotional distress that precludes learning or processing exposure exercise
(Foa et al., 2007). The PE protocol anticipates this possibility and provides
therapists with strategies that allow treatment to continue, while helping to
manage the client’s extreme distress. Although a full explication of these
strategies is beyond the present chapter, clinicians would be well served to
remember that the standard PE instructions for imaginal exposure (e.g.,
closing one’s eyes, using the present tense) are designed to maximize client
engagement with the imaginal exposure because clients tend to try to avoid
it. Therefore, when faced with the challenge of an overengaged client, the
clinician can reverse some of these standard instructions (e.g., ask the client
to complete the exercise with his or her eyes open or relate the traumatic
event in the past tense). Additional approaches that, in our clinical experi-
ence, have been used with success include having the client write a trauma
narrative and read it to the therapist, or having the client relate the events
of the trauma through a question-­and-­answer-­type conversation with the
therapist. For a more detailed description of these strategies, the reader is
referred to the PE treatment manual (Foa et al., 2007).
The PE manual also indicates that PE may not be the treatment of
choice for clients with severe comorbid conditions, such as imminent threat
of suicide or homicide, severe and recent self-­injurious behavior, and psycho-
sis (Foa et al., 2007). However, clinicians appear to think PE is more gener-
ally contraindicated for PTSD patients with comorbid symptoms or disor-
ders. For example, in a study by Becker and colleagues (2004), clinicians
considered imaginal exposure contraindicated for patients with comorbid
psychotic disorder (85%), suicidality (85%), dissociation (51%), any comor-
bid diagnosis (37%), or a comorbid anxiety disorder (32%). Similarly, van
Minnen and colleagues (2010) found that clinicians believed depression was
a contraindication for PE, especially for patients with multiple childhood
traumas. These beliefs persist, despite evidence that PE can be used effec-
tively with clients who have comorbid conditions (McLean & Foa, 2014; van
Minnen, Harned, Zoellner, & Mills, 2012).
In one of the most thorough examinations of PE in the context of comor-
bid conditions, van Minnen and colleagues (2012) reviewed the literature on
PE, including randomized controlled trials, open-label trials, and pilot stud-
ies to determine the impact of several potential comorbidities on PE’s effec-
tiveness. The conditions they examined included dissociation, borderline
personality disorder (BPD), psychosis, suicidal and nonsuicidal self-­injury,
substance use, and depression. These researchers concluded that PE can be
used effectively with clients experiencing each of these comorbid issues (van
Minnen et al., 2012). Importantly, however, when comorbid conditions are
severe, it may be best to treat the comorbid condition concurrently, or prior
Prolonged Exposure 199

to, implementing PE for the PTSD. For example, in the few studies that have
examined PE in the presence of comorbid psychosis, all patients were main-
tained on their treatment regimen for the psychosis when they completed PE
(van Minnen et al., 2012). Similarly, efforts to utilize PE with clients suffering
from severe BPD have been provided prior to or concurrent with treatment
for BPD (e.g., dialectical behavior therapy; Harned et al., 2015), and some-
times the basic PE protocol is modified, such as by adding skills training
sessions prior to initiating exposure (see van Minnen et al., 2012, for a more
thorough discussion).
PE is efficacious in reducing PTSD symptoms among patients with
comorbid depression (e.g., Foa et al., 2005). In another study, PTSD patients
with current major depression, past major depression, and no history of
major depression experienced similar reductions in PTSD with PE treat-
ment (Hagenaars, van Minnen, & Hoogduin, 2010). Although comorbid
depression has not been found to contraindicate PE, it is recommended that
therapists consider alternative treatment or crisis management prior to PE
when major depression is the primary disorder or when clients are at high
risk of suicide (McLean & Foa, 2014).
Traumatic brain injury (TBI) and PTSD commonly co-occur in military
combat veterans (Hoge et al., 2008). TBI has also been suggested as a con-
traindication for PE. However, research indicates that PE is efficacious in cli-
ents with TBI. For example, Sripada and colleagues (2013) found no differ-
ence between veterans with and without a history of mild TBI in the degree
to which PTSD symptoms were reduced by PE treatment. Similar results
emerged from a study of active duty service members and veterans (Wolf et
al., 2015). Another recent study found no differences between veterans with
and without TBI on a number of PE treatment processes, including fear acti-
vation, length and number of exposure sessions, within-­session habituation,
and extinction rate (Ragsdale et al., 2018).
Clinicians sometimes express concern about using PE when PTSD is
accompanied by dissociative symptoms. However, research indicates that
dissociative symptoms are not related to improvement or dropout from PE.
In one study, individuals with high levels of dissociation experienced similar
reductions of PTSD symptoms as did patients with low levels of dissociation
(Merrill & Strauman, 2004). Wolf, Lunney, and Schnurr (2016) found that
outcomes of PE were no different between groups of individuals with the
dissociative subtype of PTSD and those without dissociation. Burton, Feeny,
Connell, and Zoellner (2018) found similar results, suggesting that PTSD
patients with dissociation respond well to exposure-­based treatments.
When using PE with patients who have a high tendency to dissociate, it
is important to remember that the success of PE is premised on the client
being able to incorporate new information into the cognitive-­emotion net-
work associated with the trauma. This requires the client to process “new”
information while the trauma memory is activated; metaphorically, the cli-
ent must keep one foot in the present while the other revisits the past. Highly
200 Treatments for Adults

dissociative clients may find this difficult. Therefore, it might be necessary

to modify imaginal exposure instructions to help the client process new
information. This can be done by having the client complete the imaginal
exposure exercise with his or her eyes open (as with an overengager). The
client may also use simple grounding techniques (e.g., visual focusing on an
object, gripping the arms of a chair) as a means of maintaining connection
to the present. Similarly, therapists may increase their verbalizations during
the exercise (e.g., offering words of encouragement, reminders that they are
present) to help ground their clients.
Questions about using PE with PTSD clients who have substance use
disorder (SUD) persist, primarily because most prior studies of PE excluded
participants with comorbid substance dependence (although they typi-
cally included those with substance abuse diagnoses). Traditionally, clients
presenting with comorbid PTSD and substance dependence were treated
sequentially beginning with the substance use problems. Once they achieved
a period of abstinence from substance use (the exact period of time varied),
treatment for PTSD was introduced. To date, there are no studies of sequen-
tial treatment for PTSD and SUD in which the PTSD is treated first. Our
clinical experience suggests that this approach can be quite challenging,
and it is not recommended. However, several recent studies have found PE
to be efficacious when used in combination, or concurrently, with treatment
for SUD. It has been suggested that PE may be effective not only in reducing
PTSD, but may also help maintain reductions in substance use (McLean &
Foa, 2014). Some of these studies have focused on one particular substance
such as alcohol dependence (Foa, McLean, Capaldi, & Rosenfield, 2013) or
cocaine dependence (Brady, Dansky, Back, Foa, & Carroll, 2001), whereas
others have included participants who were dependent on a variety of sub-
stances (Mills et al., 2012). A manual for combined PE and SUD treatment
has been developed (Back et al., 2015).
The results described previously indicate that patients with PTSD and
co-­occurring disorders or symptoms can be successfully and safely treated
with PE. Perhaps of equal importance is the finding that PE often improves
comorbid symptomatology. Studies that examined change in depression
found that PE leads to a reduction in depression (e.g., Aderka, Gillihan,
McLean, & Foa, 2013; Asukai et al., 2010; Foa et al., 1999; Foa & Rauch,
2004; Gilboa-­Schechtman et al., 2010; Moser, Cahill, & Foa, 2010; Schnurr
et al., 2007) and in suicidal and self-­injurious urges and behaviors (Harned,
Korslund, & Linehan, 2014). PE also has demonstrated effectiveness in
reducing trauma-­related guilt (Pacella et al., 2012; Resick et al., 2002), anger
(Cahill, Rauch, Hembree, & Foa, 2003), and general anxiety (Foa et al., 2005;
Nacasch et al., 2011). In addition, PE can significantly improve social adjust-
ment and functioning (Foa et al., 2005; Foa, Yusko, et al., 2013; Shemesh et
al., 2011) and decrease physical health complaints (Rauch et al., 2009). Thus,
not only is PE effective in the face of comorbid problems, but researchers
have demonstrated its ability to broadly impact the lives of individuals with
Prolonged Exposure 201

PTSD by fostering improvement in PTSD, as well as associated symptoms,

and by improving general functioning and quality of life.

New Advances and Future Directions for PE

Recent years have seen significant advances in the application of PE in the

treatment of PTSD. Several studies have examined variations in the deliv-
ery modality, timing, and setting of PE with promising results. Although
these studies maintain the basic content and structure of the PE protocol,
they incorporate fairly major modifications that could alter the processes or
outcomes of the treatment. These changes include the use of virtual reality
technology (Maples-­Keller, Bunnell, Kim, & Rothbaum, 2017; Reger et al.,
2016), the use of daily PE sessions (e.g., Blount et al., 2014; Foa, McLean,
et al., 2018), and the delivery of PE in primary care settings (Cigrang et al.,
2015, 2017).

Virtual‑Reality‑Augmented PE
Reger and colleagues (2016) compared virtual reality exposure (VRE) to
standard PE, hypothesizing that the added multisensory virtual reality com-
ponent would increase emotional engagement during exposure, resulting
in superior outcomes relative to exposure delivered in the standard man-
ner. In this study with military personnel who had combat-­related PTSD,
VRE followed the standard PE treatment protocol (Foa et al., 2007) with two
exceptions. First, in Session 2 of VRE, the patient was briefly introduced to
the VR equipment and instructed in its use while immersed in a calm vir-
tual environment. Beginning in Session 3 of VRE, the therapist placed the
patient in a relevant VR environment and patients confronted their memory
with their eyes open, wearing a virtual reality headset. As the patient articu-
lated his or her memory, the therapist customized the scene and associated
stimuli to match the memory in relevant respects. Although VRE was effica-
cious in reducing PTSD symptoms posttreatment, improvements were not
significantly different from those achieved with standard PE. In addition,
post hoc analyses showed greater improvement in the standard PE group at
3- and 6-month follow-­up.

Massed PE
Blount and colleagues (2014) presented the case study of a U.S. military
service member treated in an intensive outpatient protocol (IOP) that deliv-
ered PE every day for 2 weeks. At the end of the 2 weeks, the client exhib-
ited clinically meaningful reductions in PTSD, depression, and anxiety, and
also no longer met the diagnostic criteria for PTSD. These gains were main-
tained at 6-month follow-­up. Foa, McLean, and colleagues (2018) conducted
202 Treatments for Adults

a randomized trial comparing “massed PE” (daily sessions for 2 weeks) to

the standard PE protocol (weekly sessions for 10 weeks). Massed PE was
found to be noninferior to standard PE. Furthermore, massed PE had a
lower dropout rate (Foa, McLean, et al., 2018).

PE in Primary Care Settings

Cigrang and colleagues (2015) examined the initial efficacy of a brief ver-
sion of PE for primary care (PE-PC) protocol. In this study, PE-PC was deliv-
ered in four 30-minute appointments over 4–6 weeks. Patients who received
PE-PC experienced significant improvements in PTSD, depression, and gen-
eral mental health that were maintained at 6- and 12-month follow-­ups. A
subsequent RCT comparing PE-PC to a minimal contact control condition
found similar results (Cigrang et al., 2017) that were generally maintained
at 6-month follow-­up, indicating that PE-PC delivered in integrated primary
care may be effective for the treatment of PTSD.

Conclusions

PE has been used and studied for more than 30 years, and the empirical lit-
erature that supports its efficacy in treating PTSD is among the most exten-
sive of any PTSD treatment. PE has been found effective in treating PTSD
following a variety of different traumatic events, and in different countries
and settings. PE is effective in treating PTSD in the presence of significant
comorbidities and, importantly, improves these other conditions as well.
Despite this evidence, some clinicians are reticent to put PE into practice. A
number of reasons for this hesitancy were described in this chapter, along
with several modifications or adjustments that can be made to the PE proto-
col to address such concerns or challenges. Many of these procedural adjust-
ments are actually reflective of the flexibility built into the PE protocol,
which appears not to be well understood by clinicians. Other adjustments to
the protocol represent substantial changes, and several of these alterations
have been the subject of empirical study (e.g., massed sessions, tele-­health
delivery, virtual reality exposure). The positive effects of PE appear robust
enough to persist, even with the variations in procedure.
Despite the strength of the research underlying and supporting PE,
there are a number of questions that remain, and additional research is
needed to provide guidance to clinicians as they incorporate this treatment
into their repertoire. For example, not all clients benefit from PE; research is
needed to help determine how to best help those clients who do not respond
to PE in its current format. Should PE be modified to treat these clients, or
would they be more effectively treated with another approach? Similarly, the
techniques of PE appear quite robust to modifications in delivery, including
massed sessions, tele-­health, and the use of virtual reality. However, research
Prolonged Exposure 203

is needed to provide guidance on whether and how such modifications

impact the effectiveness of PE for particular patients. Another area in need
of research is implementation. What tools, techniques, processes, and poli-
cies are needed to support clinicians as they begin to use PE to treat PTSD?
Beyond the practical questions outlined previously, a number of theo-
retical questions and issues related to PE require additional research. There
have been some initial attempts at identifying and understanding the mech-
anisms that underlie the changes observed with PE, but additional work is
needed. PE is sometimes conceptualized as a treatment that focuses on the
habituation of fear to achieve its gains. However, we recognize that PTSD is
associated with many emotions beyond fear, including guilt, shame, horror,
and disgust. The success of PE with clients whose traumatic memories likely
include many of these feelings other than fear suggests that the treatment
does not work solely through habituation of fear. A better delineation of the
mechanisms of change may offer the opportunity to improve the efficiency
of PE and to better identify clients who are most likely to benefit from the
treatment.
In sum, PE is a treatment with an extensive record of research support-
ing its use to treat PTSD arising from a variety of traumas. That being said,
not all clients benefit from PE and dropout rates can be high, although no
higher than in other treatments for PTSD (Imel, Laska, Jakupcak, & Simp-
son, 2013). The protocol appears robust to modifications in delivery param-
eters and useful in the context of a number of conditions that commonly
co-occur with PTSD. Despite the strengths of PE, clinicians have been slow
to adopt the protocol into their practices. Future work should examine bar-
riers to implementation and identify procedures to encourage the use of this
effective treatment.

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C H A P TE R 13

Cognitive Processing Therapy

Kathleen M. Chard, Debra L. Kaysen, Tara E. Galovski,
Reginald D. V. Nixon, and Candice M. Monson

O ur goal in this chapter is to provide a review of information critical to

understanding cognitive processing therapy (CPT) (Resick, Monson, &
Chard, 2017), its origins, and its uses as a treatment for posttraumatic stress
disorder (PTSD). The chapter begins with a description of the theoretical
underpinnings of CPT and the techniques that comprise each CPT session.
The evidence supporting CPT as a recommended PTSD treatment is sum-
marized, including a detailed appraisal of the data regarding generalizabil-
ity and gaps in the literature. The chapter concludes with recommendations
for conducting CPT with special populations and areas for future develop-
ment from clinical and research perspectives.

Theoretical Context

CPT is based on a sociocognitive or constructivist model to explain failure

to recover following trauma, and the resulting PTSD (for details, see Resick,
Monson, & Chard, 2014, 2017; Resick & Schnicke, 1993). Although informed
by information-­processing theories of fear and PTSD, in addition to tradi-
tional cognitive theory (e.g., Beck, Rush, Shaw, & Emery, 1979; Foa, Steke-
tee, & Rothbaum, 1989; Inhelder & Piaget, 1958; Lang, 1977), the role and
importance of cognitions and emotions in CPT differ somewhat compared
with these and other theoretical accounts of PTSD (e.g., Brewin, 2001; Ehlers
& Clark, 2000). According to CPT theory, when traumas occur, the brain
attempts to reconcile the meaning of the event in relation to prior existing
cognitive structures, or schemas. It is posited that recovery from trauma-
tization through natural processes or with intervention occurs because of

210
Cognitive Processing Therapy 211

accommodation of the traumatic information with existing schema. In other

words, preexisting belief structures are modified enough to be consonant
with realistic appraisals about the trauma. PTSD is thought to occur when
there is dissonance between pretrauma schemas and posttraumatic apprais-
als of the event (see Resick, Monson, & Chard, 2017, for a detailed discus-
sion). In making sense of traumatic experiences, those with PTSD attempt
to maintain their preexisting positive beliefs and alter their appraisals of
the trauma to be consistent with them. Or, if there are preexisting negative
schemas, they incorporate this information to confirm those prior negative
beliefs. In both cases, assimilation of the traumatic information takes place
because individuals attempt to incorporate traumatic information without
changing existing schemas. Symptoms are also maintained if clients radi-
cally modify their pretrauma beliefs following trauma, a process labeled as
overaccommodation. For example, they may go from believing that the world
is generally safe to believing that they are in constant threat of harm. Assimi-
lated beliefs are targeted first in the course of CPT based on the notion that
correcting historical trauma appraisals has cascading effects on here-and-
now and future-­oriented cognitions that represent problematic overaccom-
modated beliefs. Thus, the goal of CPT is to have clients develop realistic
appraisals about the trauma and adapt their schema in a balanced manner
to account for the traumatic information, and then correct overaccommo-
dated beliefs that emanate from traumatic experiences. This cognitive pro-
cessing is core to successful CPT and accounts for the title of the therapy.
A critical component of the model underpinning CPT is its position on
emotions. CPT differentiates between what are considered instinctual, hard-
wired emotions (i.e., natural emotions), such as fear in the face of real dan-
ger or sadness that might follow a loss, versus “manufactured” emotions that
are posited to be driven by effortful cognition. CPT encourages the expres-
sion of natural emotions that have been suppressed or avoided, with the view
that they will dissipate with time. Resolution of maladaptive manufactured
emotions occurs by modifying underlying unhelpful beliefs through cogni-
tive intervention.
In summary, CPT operates from a sociocognitive framework that has a
particular emphasis on addressing the meaning and interpretations clients
make of themselves, others, and the world more generally following trauma.
It encourages emotional expression while addressing unhelpful or errone-
ous thinking that leads to the problematic symptoms seen in PTSD. The
techniques and processes of CPT are detailed next.

Description of Techniques

As elaborated in a later section, CPT can be delivered in a number of for-

mats, including individual and group sessions, across various delivery for-
mats (e.g., face-to-face, tele-­health), and for varying duration, typically an
212 Treatments for Adults

average of 12 sessions on an outpatient basis. Each session follows a similar

framework: an agenda is set for the session, practice assignments given in the
previous session are reviewed and discussed, a new skill or therapy compo-
nent is introduced, practice assignments around that new component given,
and potential challenges in undertaking the new skills problem-­solved. CPT
has the same characteristics of good cognitive-­behavioral approaches, bal-
ancing structure, a collaborative, nonjudgmental therapeutic relationship,
and sometimes requiring, as discussed later, a gentle “push” by therapists to
address the avoidance that maintains PTSD and can interfere with optimal
therapeutic outcomes.
CPT can be viewed as having three phases, with the first occurring in
the early sessions (Sessions 1–3). This phase includes psychoeducation about
PTSD as a disorder of nonrecovery, socializing clients to the sociocognitive
model, and introducing the relationship between beliefs and emotions in
PTSD. This phase also includes a focus on identifying “stuck points,” or
unhelpful beliefs that are interfering with recovery. The first session of CPT
provides an opportune time to discuss the role that avoidance plays in main-
taining PTSD and for clinicians to get a sense of stuck points that might
interfere with optimal engagement of therapy (e.g., “If I think about my
trauma, it will make me worse”). Socratic dialogue is a key element of CPT,
and in this early phase it is particularly helpful in identifying these types of
beliefs. In this phase of therapy, gentle questioning and alternative perspec-
tives are explored, with a focus on assimilation-­type stuck points (e.g., self-
blame). Practice assignments are established after each session, with the first
being an impact statement. Here, a client writes a statement, approximately
one page long, explaining why she thinks the trauma happened and how it
has impacted her beliefs in the domains highlighted earlier (i.e., safety, trust,
power/control, esteem, and intimacy). In this phase, a client also completes
a worksheet, allowing her to learn about the relationship between events,
thoughts, and feelings. One format of CPT can involve the use of a written
trauma account (CPT + A). If clinicians use this format, clients are asked
to write a detailed account of their traumatic event at the end of Session 3.
The second phase of CPT (Sessions 4 and 5) comprises further pro-
cessing of the traumatic event(s), with more formal cognitive intervention.
Socratic dialogue remains a key element of therapy and, through it, clients
are helped to question and challenge their stuck points. Clients are also intro-
duced to ways to identify their idiosyncratic thinking styles that frequently
reinforce these stuck points. For example, clients learn to recognize if their
thoughts typically could be categorized as catastrophizing. A client might
therefore come to understand that his initial interpretation of an incident
in which a driver honked at him was an overreaction. That is, rather than
viewing what happened as a dangerous situation that the client perceived he
was lucky to escape without being attacked, he instead recognizes his habit
of catastrophizing around certain incidents (and in this instance, despite no
evidence that physical confrontation was ever a likely outcome). Assimilated
Cognitive Processing Therapy 213

beliefs continue to be a focus, with self-blame and hindsight bias (the idea
that one could have predicted a traumatic event or should have done some-
thing to prevent it) targeted in particular. Clients might also minimize or
distort the nature of the trauma in an attempt to make it fit with pretrauma
schemas. Thus, therapy involves labeling the event for what it was (e.g., a
rape) and addressing stuck points around accepting the traumatic event, as
it occurred. If clients are doing CPT-A, this phase also involves reading their
description of the most traumatic account in session and writing it up again
as a practice assignment, with a focus on incorporating current thoughts
and feelings.
In the final phase of CPT, clinicians assist clients to become more inde-
pendent in their challenging of stuck points and developing healthier, more
balanced beliefs. A goal here is to help clients become their own therapists,
and it is accompanied by worksheets that incorporate questions to challenge
stuck points, identifying how a point might represent a problematic pattern
of thinking, and most importantly, documenting an alternative and more
helpful belief. Throughout CPT, emotions are attended to and sometimes
amplified, with clients encouraged to express and feel natural emotions, and
to identify stuck points that might maintain unhelpful manufactured emo-
tions. Although residual assimilated beliefs are still worked on in this phase,
the majority of time is spent on overaccommodated beliefs largely in the
domains of safety, trust, power/control, esteem, and intimacy. Clients iden-
tify how stuck points in these domains can be both self- and other-­focused.
For example, most clients readily relate to the concept of poor self-­esteem;
however, their esteem of others (e.g., people from other cultures, people
associated with particular organizations) can also be negatively impacted by
trauma (e.g., “All people who are [insert race] are dangerous”). In this phase,
clients work through these domains with the help of handouts that describe
how stuck points in these areas maintain PTSD, and that give examples of
common types of stuck points and possible resolution statements. If the cli-
ent has stuck points regarding other areas, for example, religion, grief, or
moral injury, those are also addressed during this phase of therapy.
CPT usually ends when the entire protocol has been worked through,
a client’s PTSD symptoms have significantly lessened, and client and clini-
cian are in agreement that it is appropriate to terminate therapy. The CPT
manual provides directions for how to lengthen or shorten the protocol,
while still covering all of the recommended material, depending on how
quickly clients achieve the criterion outcomes. Clients are asked to write
a new impact statement that focuses on their current beliefs and thoughts
about the trauma. This is read to the therapist in the final session. It repre-
sents another indicator of PTSD recovery, with significant changes in beliefs
typically observed. The new impact statement is also helpful in identifying
any residual stuck points on which clients might need to continue to work
after therapy has ended. As with most therapeutic approaches, a review of
therapy skills is conducted, relapse prevention and plans for the future are
214 Treatments for Adults

discussed, and the importance of continued practice of skills is emphasized.

A routine review 1–3 months after therapy has ceased is recommended to
assist in identifying any unresolved stuck points and to encourage ongoing
practice of the skills.

Appraisal of the Evidence

Evidence from Randomized Controlled Clinical Trials
To date, there have been over twenty published randomized controlled trials
(RCTs) evaluating the efficacy of CPT. On the weight of this body of evi-
dence, CPT has received a Strong recommendation in the International Soci-
ety for Traumatic Stress Studies (ISTSS; 2018) guidelines for the prevention
and treatment of PTSD. This body of evidence for CPT was originally devel-
oped and tested in an open trial designed to treat PTSD in civilian female
victims of sexual assault and rape. Given the initial evidence that emerged
from this study supporting the effectiveness of CPT, Resick and colleagues
(2002) conducted the first RCT of CPT using a direct comparison design and
evaluated the efficacy of CPT as compared to the gold standard treatment at
the time, prolonged exposure (PE; Foa, Hembree, & Rothbaum, 2007), and
to a minimal attention (MA) condition. This initial RCT was conducted with
female rape survivors, most of whom (85.8%) described a history of multiple
traumatic events across their lifespan, including childhood sexual assault
(41%). The results of this first trial were strong, with participants in both
CPT and PE demonstrating significant improvements in PTSD and depres-
sion and improvements in both active conditions being significantly greater
than those observed in the MA group. In perhaps the most extensive long-
term follow-­up study in the PTSD literature to date, Resick, Williams, Suvak,
Monson, and Gradus (2012) assessed the maintenance of treatment gains
5–10 years after the completion of treatment in this trial and found that
gains were well maintained for participants who received both CPT and PE.
Over the course of the next decade, several additional RCTs were
designed and conducted with the goal of building on Resick and colleagues’
(2002) foundational trial and advancing the understanding of the mecha-
nisms of action, as well as exploring flexible approaches to delivering treat-
ment and optimizing outcomes. First, to better understand the relative con-
tribution of the different theorized therapeutic elements of CPT, Resick,
Nishith, Weaver, Astin, and Feuer (2008) conducted a dismantling trial com-
paring the treatment protocol with the account to the treatment protocol
without the account, to a condition that focused only on writing the account
of the trauma and then processing the associated emotions. Participants
in all three conditions improved significantly on PTSD, depression, anger,
guilt, anxiety, and shame; however, those who received CPT without the
account improved faster and had significantly less dropout from treatment.
These study results suggest that change in trauma-­related beliefs is a critical
Cognitive Processing Therapy 215

mechanism of action in CPT. This study has important clinical implications,

because it gives both therapists and patients demonstrably equally effec-
tive choices in delivering and receiving versions of CPT, thereby optimizing
patient agency and increasing the likelihood of engagement and retention.
Galovski, Blain, Mott, Elwood, and Houle (2012) then explored the ben-
efit of modifying the length of therapy such that therapy’s end be deter-
mined by patient progress versus by a prescribed number of sessions. Flex-
ibly administering the protocol yielded higher response rates; by the end of
the study, 92% of the participants no longer had a diagnosis of PTSD. As a
result of this study, CPT is now administered over a variable number of ses-
sions, depending on patient needs. This study further assessed the impact
of inserting non-­trauma-­focused crisis sessions into the protocol (in the case
of midprotocol major psychosocial stressors or non-­trauma-­related patient
crises) and found that CPT was able to easily accommodate intentional and
thoughtful divergence from the protocol. Importantly, dropout rates were
relatively low in this trial (i.e., 25%), suggesting that variable lengths of treat-
ment (i.e., allowing patients to be done when they are improved and remain
in therapy longer if they need additional assistance) and specific attention
to major life stressors (with forethought as to how to return to the protocol
as expediently as possible) may increase patient engagement and retention.
Consideration of the potentially more profound impact of early expo-
sures to trauma in treating PTSD, particularly childhood sexual abuse, has
long been an empirical and clinical concern. Clinicians and researchers
alike have noted challenges with chronic abuse that occurs during impor-
tant developmental years and wondered as to whether brief, protocol-­driven
therapies are adequate in cases of complex trauma histories. Chard (2005)
expanded the CPT protocol to 17 sessions and compared this treatment
to an MA wait-list condition. Adult study participants had all experienced
childhood sexual abuse and the majority reported chronic abuse histories
(57% recalled over 100 incidents of abuse). CPT participants showed signifi-
cantly greater improvement than MA participants, with large effect size dif-
ferences on PTSD and depression outcomes. This trial provides support for
the effectiveness of CPT in cases of chronic PTSD stemming from trauma
exposures during patients’ formative years. Ahrens and Rexford (2002) also
tested the CPT protocol with adolescents with a history of child interper-
sonal trauma. Their study included 38 incarcerated male adolescents who
had typically experienced multiple traumas, largely interpersonal violence
in nature. Eight sessions of CPT were compared to a wait-list control, and
patients in the CPT condition reported, on average, a 50% reduction in
PTSD symptoms via a self-­report measure.
In an effort to assess the generalizability of CPT to noncivilian pop-
ulations, several RCTs were conducted with both veteran and active duty
military samples. The generalizability to military populations is particularly
important, given the smaller effects of trauma-­focused treatment in this
population as compared to those observed in civilians (Steenkamp, Litz,
216 Treatments for Adults

Hoge, & Marmar, 2015). The first CPT study conducted with a veteran sam-
ple included primarily male veterans (93% male; 80% from the Vietnam era;
78% with combat-­related trauma) and compared the 12-session CPT pro-
tocol with a 10-week wait list (Monson et al., 2006). CPT participants dem-
onstrated greater improvements in PTSD than the wait-list controls, with
large effect size differences. Suris, Link-­Malcolm, Chard, Ahn, and North
(2013) also conducted a CPT trial with U.S. veterans. This study specifically
included veterans who had suffered military sexual trauma (MST), and the
sample was 85% female. CPT was compared to an active treatment condi-
tion, present-­centered therapy (PCT), and CPT demonstrated a large effect
for PTSD, with PCT having slightly less significant improvements. Finally,
Sloan, Marx, Lee, and Resick (2018) recently compared CPT to written expo-
sure therapy (WET) in a sample of civilian and veterans (52% male) who had
been diagnosed with PTSD secondary to different types of trauma. CPT
and WET were largely equivalent in effectively treating PTSD. CPT has also
been tested in veterans outside the United States. Forbes and colleagues
(2012) compared CPT to an active largely CBT-­focused treatment as usual
(TAU) condition in a sample of Australian veterans (97% male and 67%
from the Vietnam era) attending for care at a veterans’ counseling service.
Study results indicated that veterans who participated in CPT improved sig-
nificantly more in PTSD symptoms than those in TAU, with a large effect
size reported. Resick and colleagues (2015) first tested CPT in an active duty
military sample and compared CPT to PCT. Both treatments showed signifi-
cant improvement over time, with CPT resulting in a slightly larger effect,
although not significantly different from PCT. These comparison trials
continue to demonstrate strong evidence supporting the efficacy of CPT in
military and active duty populations. However, they also indicate substantial
room for improvement in terms of overall outcomes and retention.
CPT has been tested in a range of different contexts and with diverse
populations. The efficacy of CPT has been demonstrated in randomized con-
trolled clinical trials internationally, including in the Democratic Republic
of Congo, Iraq, Australia, and Germany (Bass et al., 2013; Bolton et al., 2014;
Butollo, Karl, Konig, & Rosner, 2016; Nixon, 2012; Weiss et al., 2015). The
therapy has been tested as well across diverse populations within the United
States, including Bosnian war refugees (Schulz, Resick, Huber, & Griffin,
2006), African American clients (Lester, Artz, Resick, & Young-Xu, 2010),
Latinos (Marques et al., 2016; Valentine et al., 2017), and Native Americans
(Pearson, Kaysen, Huh, & Bedard-­Gilligan, 2019). CPT has been translated
into 12 different languages (Resick, Monson, & Chard, 2017) and has been
shown to be effective when delivered through an interpreter (Schulz et al.,
2006).
CPT continues to evolve, with the overarching goal of developing the
therapy to enhance reach, access, and treatment for more diverse groups of
trauma survivors. Toward this end, several RCTs have utilized augmentation
designs or directly compared different versions of the protocol or methods
Cognitive Processing Therapy 217

of administration of CPT. Augmentation studies have sought to address

sleep impairment prior to commencing trauma-­ focused treatment and
found that sleep impairment could be significantly improved, and that the
improved sleep augmented recovery from depression, but not from PTSD
(Galovski et al., 2016). In a second augmentation study, Kozel and colleagues
(2018) added transcranial magnetic stimulation (TMS) to CPT to improve
outcomes in veterans with PTSD and showed a significantly greater effect
on PTSD in the TMS + CPT condition, as compared to a sham TMS + CPT
control. A series of studies were also conducted comparing the method of
treatment delivery of CPT. For example, several noninferiority trials found
that delivering CPT via tele-­v ideoconferencing was noninferior to delivering
the therapy in person for primarily male veterans (Morland et al., 2014), for
civilian and veteran women (Morland et al., 2015), and in post-9/11 veterans
(Maieritsch et al., 2016). Importantly, the groups did not differ with respect
to therapeutic alliance, treatment compliance, and treatment satisfaction
(Morland et al., 2014), suggesting that treatment via tele-­v ideoconferencing
is a feasible, palatable, and engaging modality of care.
Finally, although CPT was originally developed as a group therapy,
the intervention has primarily been tested as an individual therapy. Resick,
Wachen, and colleagues (2017) sought to evaluate the relative efficacy of
group- versus individually administered CPT with active duty service mem-
bers and found that participants improved significantly in PTSD and depres-
sion in both treatment conditions, but improvements in PTSD were signifi-
cantly greater when the therapy was administered individually.

Evidence from Clinical Effectiveness Studies

PTSD rarely occurs in isolation, and treatment trials have assessed the
effects of the intervention on a host of clinically complex patient popula-
tions. A number of studies assessing the effects of treatment on second-
ary outcomes and the effects of the decreases of PTSD and depression on
comorbid disorders and conditions have been published. To date, studies
have shown CPT to be effective in individuals who are also diagnosed with
one or more personality disorders (Clarke, Rizvi, & Resick, 2008; Farmer,
Mitchell, Parker-­Guilbert, & Galovski, 2017; Walter, Bolte, Owens, & Chard,
2012). Kaysen and colleagues (2014) found that participants with current or
past histories of alcohol use disorders recovered as well from PTSD as com-
pared to participants without this comorbidity. In a later study with Native
American women with PTSD, substance use, and HIV risk behavior, CPT
was associated with significant reductions in PTSD severity, high-risk sexual
behavior, and frequency of alcohol use (Pearson et al., 2019).
Traumatic brain injury (TBI) is a signature wound of American combat
veterans who served post-9/11 and has high rates of comorbidity with PTSD
(Hoge et al., 2008). Treating PTSD with CPT as part of a larger 8-week resi-
dential VA treatment program for comorbid PTSD and TBI was found to be
218 Treatments for Adults

beneficial, including for individuals with moderate to severe TBIs (Chard,

Schumm, McIlvain, Bailey, & Parkinson, 2011; Walter et al., 2012; Walter,
Varkovitzky, Owens, Lewis, & Chard, 2014). In addition, Jak and colleagues
(2019) found that CPT with or without added cognitive rehabilitation train-
ing was effective in treating veterans with PTSD and a history of TBI in a
randomized trial. CPT has been successfully implemented in an urban com-
munity mental health clinic as the trauma recovery portion of a larger pro-
gram designed to provide mental health services to individuals diagnosed
with severe mental illness, having unstable housing, and recently diverted
from jail (Feingold, Fox-­Galalis, & Galovski, 2018).
Additional treatment gains on impairment in functioning, comorbid
symptoms, and clinical correlates of PTSD have been reported across RCTs
and effectiveness studies, including improvements in depression, suicidal
ideation, health-­related concerns and sleep, sexual functioning, physiologi-
cal reactivity, dissociation, occupational performance, and functioning
across other important life domains (Galovski, Monson, Bruce, & Resick,
2009; Galovski, Sobel, Phipps, & Resick, 2005; Gradus, Suvak, Wisco, Marx,
& Resick, 2013; Griffin, Resick, & Galovski, 2012; Mesa, Dickstein, Wooten,
& Chard, 2017; Monson et al., 2012; Resick, Williams, et al., 2012; Speicher,
Walter, & Chard, 2014; Wells et al., 2018). CPT is a relatively robust treatment
that has been utilized in a variety of contexts, with research and implemen-
tation studies that have evaluated aspects of optimal delivery of the inter-
vention. Also of note, in separate dissemination initiatives with U.S. and
Australian veterans, very large effect sizes were found in naturalistic data
collection of therapists’ first cases using CPT—thus showing that even in the
consultation process, therapists from different professions and with various
levels of clinical expertise can facilitate significant positive changes for their
clients (Chard, Ricksecker, Healy, Karlin, & Resick, 2012; Lloyd et al., 2015).
Taken together, these studies showed that CPT is robust with demonstrable
effect when administered in variable lengths, with added crisis sessions, with
or without a trauma account, when delivered through video­conferencing,
and in group, individual, or combined formats. It should be noted that in all
of these trials, the actual protocol content was preserved with careful atten-
tion to fidelity. The richness of this clinical effectiveness and implementa-
tion literature helps inform the guidelines for providers in delivery of CPT
across varying clinical contexts.

Practical Delivery of the Recommendations

Setting the Stage for CPT Delivery
Prior to starting CPT, it is essential to ensure that the clinical setting will
allow for CPT to be delivered in a way that it is likely to be effective. As
noted previously, CPT has been delivered in a variety of settings, includ-
ing outpatient clinics, intensive day programs, low resource areas, and
Cognitive Processing Therapy 219

residential treatment programs (Bass et al., 2013; Walter et al., 2014). When
offering the various formats of CPT to a client, we recommend relying on
client preference when at all possible. Although many clients want to tell
their trauma account to a therapist, we have found that just as many do
not want to focus on the details of the event and would prefer moving to
the cognitive challenging phase sooner. Thus, we find it helpful to discuss
the treatment options with each client prior to starting CPT and allowing
them to make an informed choice. Individual CPT is recommended to be
delivered in 60-minute psychotherapy sessions, typically delivered weekly or
biweekly. Group CPT consists of 90- to 120-minute group sessions, delivered
weekly or biweekly. There is new, promising research that has examined
more frequent sessions, such as three times per week or even daily sessions,
which suggests that this type of spacing for sessions does not reduce efficacy
and may reduce dropout (Bryan et al., 2018; Zalta et al., 2018). However, at
the present time, the findings on more frequent dosing of treatment than
twice weekly are based on open trials or single case studies. This has great
promise for clients whose work, school, family demands or geographical
limitations necessitate they receive treatment in a short period of time, or
for clinical contexts such as inpatient settings, where more frequent sessions
are necessary due to the length of stay. In these studies, clients are asked to
complete all practice assignments prior to each session. In contrast, spacing
out CPT more than once weekly may increase dropout and may also reduce
the therapy’s effectiveness (Gutner, Suvak, Sloan, & Resick, 2016). This can
be a challenge in clinical settings with high caseloads or with a treatment
model of monthly sessions. Thus, it is important when working with both
clients and clinic administrators to ensure that at least weekly sessions are
feasible.
CPT relies on the concept of “treat to target,” which means that treat-
ment plans are oriented toward achieving a well-­defined, clinically relevant
end-­target. The assumption with this model is that the treatment plan will
be both dynamic and responsive and will adjust the intervention based
on measurement of clinical response. In the case of CPT, this means that
clinicians should be using standardized measures to monitor the client’s
response to treatment (i.e., change in PTSD symptom severity), ideally
weekly. By tracking PTSD symptom improvements frequently and reliably
over the course of CPT, clinicians can help to ensure that the treatment is
addressing core symptoms effectively and can help to identify times when
CPT has gone awry early enough to correct the course. The PTSD checklist
(PCL; Blevins, Weathers, Davis, Witte, & Domino, 2015) is a common tool
used for this purpose, as it is both free and standardized. Clinicians should
also use standardized instruments to track other symptoms that may be of
clinical importance, such as depression, substance use, panic attacks, or sui-
cidal ideation/self-­injury. Monitoring changes in symptoms weekly accom-
plishes several goals. It allows both client and therapist to observe CPT
progress. For therapists, this is an active process and allows CPT clinicians
220 Treatments for Adults

to notice whether symptoms are improving and, if they are not, to address
these barriers. It also can provide a helpful point of discussion for both cli-
ent and therapist around practice compliance and practice engagement. It
can be helpful if the clinical setting is one in which clients can fill in the
outcome measures in the waiting room or prior to beginning each session
and where these measures can be tracked over time.

Who Is Appropriate for CPT?

In selecting clients for CPT, the existing clinical trials literature is used as
a guideline. In general, these trials have had relatively minimal exclusion
criteria, which often mirror the realities of most clinical settings. Exclusion
criteria for CPT have generally been based on issues around clinical safety
(suicidal/homicidal ideation with active intent, active psychosis or mania,
substance dependence, active and severe nonsuicidal self-­injury) or around
ensuring that treatment effects can be attributed to the intervention (i.e.,
stability on psychiatric medications, typically for 1–2 months). Based on
the literature, reviewed previously, individuals have been included in tri-
als for CPT with personality disorders and other psychiatric disorders (e.g.,
depression, obsessive compulsive disorder, atttention-­deficit/hyperactivity
disorder, panic disorder, traumatic brain injury), as well as with both child-
hood and adult traumatic events, and with both single-­incident and chronic
trauma experiences. Thus, in general, CPT is a flexible intervention that can
be applied to a broad array of individuals with PTSD, or subthreshold PTSD
(Dickstein, Walter, Schumm, & Chard, 2013).
In determining whether CPT is a good fit for a particular client, there
are various factors to consider. First of all, it is essential to determine that
a client has PTSD. This may seem self-­evident, but for the most part, CPT
has been tested for individuals presenting with a clinical diagnosis of PTSD.
Many individuals who have experienced traumatic events may present for
treatment with other disorders and may not have PTSD. In these cases, it is
more appropriate to use an evidence-­based intervention for the presenting
complaint. In cases where an individual may have subthreshold PTSD, CPT
may be an appropriate intervention should it seem as if the trauma-­related
symptoms are what is driving client distress and another intervention does
not make more sense in terms of one’s case conceptualization.
Other factors to consider are safety-­related concerns, such as suicidal-
ity, homicidality, and nonsuicidal self-­injury. In these cases, it is essential
that clinicians obtain a comprehensive history of the behavior. Factors such
as the recency, frequency, and severity of the behavior, whether it is acute
or chronic, the client’s overall level of impulsivity, his or her level of sup-
ports and coping skills, and the degree/frequency with which he or she is
using drugs and alcohol should be considered. For individuals whose sui-
cidal behavior or nonsuicidal self-­injurious behavior are likely to lead to CPT
needing to be interrupted, interventions like the collaborative assessment
and management of suicidality (CAMS) or dialectical behavior therapy may
Cognitive Processing Therapy 221

be helpful prior to, or concurrent with, the start of CPT to assist with sta-
bilization, although this has never been directly examined in a CPT trial
(Harned, Korslund, Foa, & Linehan, 2012; Jobes et al., 2017; van Minnen,
Harned, Zoellner, & Mills, 2012). It is also helpful to examine how PTSD
symptoms may fit in with these behaviors. In many cases, treating PTSD
is an efficacious way of reducing suicidal ideation, as long as the client can
engage in CPT (Gradus et al., 2013).
For substance use, individuals were included in earlier CPT research tri-
als if they met criteria for mild to moderate substance abuse disorders (i.e.,
the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders
[DSM-IV]; American Psychiatric Association, 1994) and if they agreed to
not use before, during, or after homework assignments or sessions. Individu-
als were excluded on the basis of severe substance use disorders (DSM-IV
dependence). This exclusion criterion was established due to unexplored
concerns about CPT leading to increased risk of substance relapse. How-
ever, more recent research has failed to demonstrate that trauma-­focused
therapies lead to substance relapse more than substance-­use-­focused thera-
pies or relaxation treatment (Killeen et al., 2008; Roberts, Roberts, Jones,
& Bisson, 2015; Simpson, Lehavot, & Petrakis, 2017). Moreover, unremit-
ted PTSD increases the risk of substance use relapse (Ouimette, Coolhart,
Funderburk, Wade, & Brown, 2007; Ouimette, Moos, & Finney, 2003; Read,
Brown, & Kahler, 2004). Recent studies have only excluded individuals who
were in need of current detoxification procedures, and typically, these indi-
viduals start the studies right after detoxification is complete (Resick, Mon-
son, & Chard, 2017). Thus, the decision for the clinician is whether CPT is
more likely to lead to harm than just treating the substance use alone or
engaging in concurrent treatment. Similar to safety-­related behaviors, fac-
tors such as the recency, frequency, quantity, and severity of use; chronicity;
and the length of time the client has been able to maintain sobriety must
be considered. Some clinicians may not be comfortable assessing substance
use, although there are brief screening measures that may be helpful in this
regard (Hays, Merz, & Nicholas, 1995; Tiet, Finney, & Moos, 2008). In addi-
tion, it is critical to assess whether the client has physiological dependence,
as acute withdrawal from some substances such as alcohol can require medi-
cal attention. During treatment, it is important that clinicians monitor quan-
tity and frequency of use during treatment and monitor urges to use. It is
not yet known to what extent substance use over the course of CPT may
impact clinical outcomes. Thus, prior to starting CPT, it can be helpful to
create a contract around use and set up guidelines for how much and when
the patient is using substances. For example, it is common to establish limits
making clear that clients will not be seen if they are intoxicated or high.
Clinicians may also wish to set up guidelines requiring clients to limit their
use before or after practice completion, or to use CPT cognitive skills prior
to deciding to use. Some of these limits may also depend on where a client is
in terms of his or her own substance use treatment goals and the severity of
current use and presence/absence of a substance use disorder.
222 Treatments for Adults

A common concern for clinicians is what to do with clients when the

traumatic event occurred long ago or whether CPT is appropriate for cli-
ents who have extensive trauma histories, especially with chronic traumatic
events. Despite these concerns, the evidence suggests that CPT appears to
work well even with clients having extensive and complex trauma histories.
There may be challenges with selecting an index trauma. However, empiri-
cal evidence indicates that multiple trauma exposures or a history of child-
hood trauma does not appear to interfere with CPT treatment outcomes
(Chard, 2005).
In terms of other factors that might influence the delivery of CPT, such
as issues surrounding literacy, or working with clients who have experienced
a TBI, clients with physical disabilities that may interfere with writing or
reading, or clients with learning disabilities, CPT is still possible to imple-
ment, but may require some modifications. Modifications can include using
simplified worksheets or worksheets formatted in ways that make them
easier for clients to complete (i.e., a more linear presentation of material,
simplified language, larger text). Clients who cannot write can voice-­record
their responses. In international contexts with very low levels of literacy,
CPT materials have been simplified and clients have even memorized the
materials. The key point is that there still will be regular practice working
on the core skills of CPT: cognitive processing, identification of stuck points
and maladaptive emotions, learning to challenge those stuck points, and
moving toward creation of more balanced beliefs.
Trials in low-­resource settings have, by necessity, utilized pioneering
and less traditional rigorous methodology to achieve study aims in challeng-
ing circumstances (such as lack of normed instruments available in local
languages, lack of trained mental health professionals for assessments or
treatment delivery, armed conflict) and locales (such as lack of electricity,
Internet access and technical support, physical infrastructure). The chal-
lenges to conducting an RCT in the Democratic Republic of Congo, for
example, include working with study assessors and therapists with mini-
mal training in mental health, which necessitates increasing training time,
removing jargon from the treatment manual and training materials, training
in the provision of clinical supervision, conducting training sessions using
more hands-on practice, and providing more training in basic psychother-
apy or assessment skills. Additional challenges working in the Democratic
Republic of Congo and in Northern and Southern Iraq include delivering
the therapy and assessments, and training, in multiple languages; creat-
ing materials to help promote basic buy-in around talk therapy; managing
extensive travel distances for clients, providers, and supervisors given poor
structural infrastructure; and addressing the delivery of a trauma-­focused
therapy in an active conflict setting where, in some cases, supervisors are
not able to travel to sites to observe sessions and clients and counselors may
need to sleep outside their homes due to concerns about safety in their
communities.
Cognitive Processing Therapy 223

Common Pitfalls in CPT Delivery

Throughout the course of CPT, one of the common pitfalls in delivery
occurs when therapists themselves avoid or when they reinforce client avoid-
ance. Therapist avoidance can manifest itself in adding extra sessions prior
to starting CPT without a strong clinical rationale. It can also manifest itself
as repeating sessions during the early and middle phases of CPT, either out
of a concern that the client “masters” the skill or in response to incomplete
practice. At times, therapist avoidance may be prompted by a therapist’s
own stuck points about the treatment process (i.e., “I’ll make them worse,”
“My client won’t be able to tolerate this,” or “I am hurting my client”). It is
extremely helpful when good supervision or peer consultation is available,
both to identify therapist avoidance and to challenge therapist stuck points.
Therapists reinforcing client avoidance can happen in a variety of ways.
For example, therapists may try to reassure clients with regard to out-of-­
session practice noncompliance (“That’s OK that you did not do the assign-
ment”), may fail to reassign practice assignments as recommended in the
manual, or may avoid talking about the index trauma or asking for details
about it. They may inadvertently shut down emotions rather than letting a
client sit with his or her natural emotions or they may allow the client to
avoid talking about the traumatic events during the session.
Therapists also may fail to notice and respond appropriately to client-­
level avoidance, inadvertently reinforcing these behaviors. As client avoid-
ance is conceptualized in CPT as any behavior that serves to escape trauma-­
related cues, emotions, and reminders, it can manifest in multiple ways and
can, at times, be difficult to identify. In general, with avoidance behavior in
CPT, the optimal response is to identify the behavior, motivate the client
to make a change (i.e., not avoiding), and address stuck points around the
avoidance. With regard to practice noncompliance, this would include com-
pleting the assignment in session, followed by reassignment of the missed
practice and assignment of the new practice.
Another common pitfall in CPT is the failure to identify and address
assimilation-­related stuck points, especially in the early sessions (Sessions
2–5). Often overaccommodation stuck points are easier for clinicians and
clients to hear and identify. For clients, these frequently are easier beliefs
to discuss, because they are more distal from the traumatic event itself.
Assimilation stuck points such as those reflecting self-blame, undoing,
and hindsight bias may be more subtle. Also, as these stuck points may be
linked to intense emotions about the event itself, they may contribute more
to client-­related avoidance. However, the failure to address and challenge
these assimilated stuck points is likely to leave PTSD symptoms untouched
and also makes it more difficult to gain traction on the overaccommodated
stuck points.
Another challenge in CPT can be helping the client pick the “index
trauma.” An index trauma in CPT refers to the trauma that the client
224 Treatments for Adults

defines as his or her most traumatic event. For some clients, identifying a
“most distressing traumatic event” can be a challenge, especially for clients
with more extensive trauma histories. To determine the index trauma, it can
be helpful to question which trauma is interfering with a client’s function-
ing the most and/or which one is most associated with PTSD symptoms
(e.g., “Which one do you want to avoid talking about the most?” “Which
event shows up more than others in intrusive memories or nightmares?”).
At times, clinicians may recognize the need to focus on a different traumatic
event, either because the client did not disclose the most distressing trauma
in Session 1 or because, as symptoms from the initial trauma resolved, it
became clear that another traumatic event was actually fueling symptoms
and stuck points. In these cases, it is important to include the new traumatic
event and continue working on relevant stuck points. It is acceptable in CPT
to work on stuck points from multiple traumatic events.
Over and above all the pitfalls mentioned, the biggest area where CPT
therapists struggle is in the execution of Socratic dialogue. Socratic dialogue
is the bedrock of CPT and is the art of asking curious questions to guide new
learning. This includes learning how to identify what we are saying to our-
selves, to question the accuracy of those beliefs, and to generate new, more
balanced thoughts. Therapists may be tempted to tell clients the answer or
to assume that they already know what the answer is. At times, it can even
seem more expedient to try to jump ahead in the process, rather than to
pursue questions as a way of guiding the therapeutic process. However, what
is most important in guiding change is the process of discovery for the client
and the ability to learn to make these discoveries on one’s own that tends
to enhance perceived self-­efficacy and to create new learning. In addition,
in other therapies, when changed beliefs are uttered by the client rather
than the therapist, they are more predictive of behavioral change (Amrhein,
Miller, Yahne, Palmer, & Fulcher, 2003; Moyers et al., 2007), although this
has not been tested in CPT directly. The process of Socratic dialogue should
be one that is collaborative and warm; this creates a safe environment within
which to look, together, at some of the most difficult parts of the traumatic
event. As such, if the therapist finds that he or she is trying to win an argu-
ment or to convince the client of a certain perspective or point of view, then
the therapist has exited the realm of Socratic dialogue. Defensiveness on the
part of the client is conceptualized as a behavioral indicator that the thera-
pist is too change-­oriented or has moved out of Socratic dialogue and should
return to a mode of curious exploration.

Training and Support in the Delivery of CPT

For therapists who are not trained in CBT, delivery of manualized treatments,
or cognitive interventions, moving to CPT treatment delivery may represent
a shift and they may need more training and consultation in making those
changes. There are online trainings in CPT (https://cpt.musc.edu or https://
Cognitive Processing Therapy 225

deploymentpsych.org/online- ­courses/cpt) that can help interested providers gain

a foundation in core CPT skills prior to training, or strengthen their skills
after attending a training session. Attending an in-­person CPT workshop is
strongly recommended and required to become an approved CPT provider,
and to gain a better sense of how to deliver the treatment with fidelity. These
trainings involve didactic content, role plays, and video of the therapy being
conducted with various types of clients. This is also a helpful medium within
which to see how different therapists maintain their voice as clinicians while
still delivering CPT that is true to the model. Following attendance at a CPT
workshop, it is recommended that clinicians attend supervision or case con-
sultation with an approved CPT trainer/consultant. The type of case oversight
depends on the clinicians’ setting and whether experienced CPT clinicians
are on-site; it also depends on the therapists’ prior level of related training
and expertise. The current recommendation is that a therapist complete 20
group consultation sessions or complete 7.5 hours of individual supervision
to become an approved CPT provider. It is also recommended that they start
at least four cases or two groups, so they can complete at least two individual
cases or two groups. This is to ensure they experience enough of the therapy
while they have the support of consultation or supervision. This allows for a
place to discuss issues, such as those touched on in this chapter: who is an
appropriate client for CPT, how to deliver CPT with fidelity to real-world cli-
ents, and what to do when one encounters challenges along the road.

Future Developments

Although the efficacy and effectiveness research that has accumulated on

CPT is compelling, there is room for further developments to ultimately
improve the health and well-being of those with PTSD. While a great major-
ity of clients receiving CPT show dramatic improvement in their symptoms,
we know that some clients have little to no improvement in their symptoms
during CPT. There is little consistent data across studies predicting who does
not do as well in CPT based on client variables, but two common themes that
have emerged are lack of therapist fidelity to the protocol and problems with
homework compliance (Farmer et al., 2017; Wiltsey ­Stirman et al., 2018).
Currently, the CPT manual recommends that avoidance and lack of home-
work completion be addressed very early in treatment through brainstorm-
ing about types of avoidance that may emerge and completing A-B-C sheets
in session on the thoughts that may be reinforcing the avoidance behavior.
If the client continues to be largely noncompliant, the CPT manual recom-
mends considering termination around Sessions 5 and 6 as there is little
evidence to suggest that the client will get better when not actively partici-
pating in all aspects of the treatment protocol. In other situations, the client
may be compliant with the therapy, but still show minimal improvement in
his or her PCL assessment scores. This may be the result of an undiscussed
226 Treatments for Adults

trauma that needs to be identified with its resulting stuck points, but the
lack of improvement can also be caused by internal or external factors that
motivate the client to remain symptomatic. We encourage the therapist to
help the client identify the reasons why and, when possible, look for the
stuck points that may be inhibiting change. If a client continues to show
minimal improvement in CPT, it may become necessary to discuss available
alternative treatment strategies that the client might find more effective.
Future studies are examining which of the evidence-­based treatments are
more effective for which type of client, and this may help to improve client
outcomes in the future (Schnurr et al., 2015).
With research showing that various components of CPT work (Resick
et al., 2008), the next generation of CPT research should aim to determine
treatment matching based on client characteristics, their social milieu, and
treatment context. Relatively few client characteristics have been elucidated
predicting treatment response to CPT. One factor found to predict a differ-
ential response to different versions of CPT is level of dissociation, with those
higher in dissociation responding better to CPT + A versus CPT or written
accounts only (Resick, Suvak, Johnides, Mitchell, & Iverson, 2012). Galovski
and colleagues’ (2012) CPT variable-­length study revealed that those with
more depressive symptoms required more sessions of CPT. Increasing cli-
ent age (Rizvi, Vogt, & Resick, 2009), lower social functioning (Lord et al.,
2019), and higher levels of anger (Lloyd et al., 2014) have also been found
to predict poorer outcomes. Most of these factors have only been found in
single studies and in certain samples, and thus require replication. More
studies testing potential treatment moderators will help provide guidance to
clinicians and their patients with regard to the best match and dose of treat-
ment for a given client. In the meantime, client preference for treatment
has been found to predict PTSD treatment outcomes in the broader PTSD
field (Zoellner, Roy-Byrne, Mavissakalian, & Feeny, 2018) and should guide
selection of the version of CPT delivered. Moreover, there are certain low-­
resource contexts in which different components of CPT might be offered.
Although more research on CPT and CPT + A is ongoing, it is important to
remember that the written-­accounts-­only version was not significantly dif-
ferent from the other conditions at posttreatment and follow-­up in the one
dismantling trial with female interpersonal violence victims conducted to
date (Resick et al., 2008). Future research on this treatment component may
help facilitate access to treatment in certain contexts with few clinicians or
limited training.
The next generation of CPT research will extend to address other essen-
tial health care delivery questions and adjunctive interventions to optimize
CPT outcomes. As reviewed previously, there have been creative efforts to
address such questions, including the examination of CPT dosing, delivery
via video technology, delivery in low-­resource areas, and delivery in resi-
dential settings. Efforts are afoot to test the massed dosing of CPT (i.e.,
Cognitive Processing Therapy 227

sequential days of delivery; Wachen, 2019) and via therapist-­assisted online

delivery (Monson, Fitzpatrick, & Wagner, 2017) to facilitate more efficient
outcomes and access to treatment, respectively. With regard to optimizing
CPT with adjunctive interventions, there is at least one study beginning to
test the addition of 3,4-methylenedioxy-­methamphetamine (MDMA; Wag-
ner & Monson, 2018) to potentiate the effects of CPT, especially in cases of
refractory PTSD.
Another avenue of potential research is how much CPT might be sim-
plified or “degraded” and still maintain its efficacy. This is a natural exten-
sion of determining the active ingredients of CPT from the essential ones.
As concrete examples: Do clients need to learn both challenging questions
and patterns of problematic thinking? Would a focus on altering assimilated
thoughts only yield the same outcomes? Are the behavioral assignments in
Sessions 10 and 11 essential? Do clients need to progress through a series of
worksheets designed to challenge cognitions? This vein of research aimed at
developing as parsimonious a treatment as possible has important implica-
tions to client uptake, retention, ease of delivery, and training clinicians in
CPT.
Related to training clinicians in CPT, there is room to improve access
to CPT by understanding the best methods to train clinicians in the model.
Monson and colleagues (2018) found significantly better patient engagement
and symptom outcomes when clinicians learning the therapy received expert
postworkshop consultation in the model. More implementation research
needs to be conducted to determine not only how to bring clinicians up to
fidelity in CPT, but also how to sustain such practices over time and with
efficient use of resources. On the latter point, some health care settings with
PTSD clients most in need do not have the resources to train clinicians or
experience significant staff turnover, making travel to in-­person workshops
offered at set times a barrier to learning and delivering CPT. Implementa-
tion studies that assess the noninferiority of other methods to train clini-
cians (e.g., on-­demand online workshop training) and determine fidelity to
the treatment (e.g., self-­assessment) are needed to identify the most efficient
methods in clinician training.
In summary, the past 25 years have yielded a significant number of
RCTs and clinical effectiveness studies that not only demonstrate the effi-
cacy of CPT in creating lasting changes in PTSD symptoms, but also show
how effective CPT is in treating a broad spectrum of comorbid conditions
that are often considered complex presentations by clinicians. Studies have
borne out the utility of CPT’s various forms (e.g., with and without accounts,
modified worksheets) and flexible treatment options (e.g., group, individual,
combined) in helping clients suffering from the aftermath of a variety of
traumatic events in many parts of the world. We anticipate that current and
future research efforts will lead to further refinement of CPT, which ulti-
mately will translate to better outcomes for our clients.
228 Treatments for Adults

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C H A P TE R 14

Eye Movement Desensitization

and Reprocessing Therapy
Francine Shapiro, Mark C. Russell, Christopher Lee,
and Sarah J. Schubert

Esizesyegrative,
movement desensitization and reprocessing (EMDR) therapy is an inte-
client-­centered psychotherapy (Shapiro, 1989, 2018) that empha-
the brain’s information-­processing system and memories of disturbing
events as the bases of psychopathology. EMDR therapy focuses on experi-
ences contributing to both pathology and resilience. Randomized controlled
trials (RCTs) have established the efficacy of EMDR therapy and resulted
in its recognition as an evidence-­based treatment (EBT) for posttraumatic
stress disorder (PTSD). In this chapter, we review the theory underlying
EMDR therapy and the evidence base supporting it. The practical aspects
and challenges of implementing EMDR therapy in clinical practice are then
discussed.

Theoretical Context

The adaptive information processing (AIP) model guides the therapeutic

application of EMDR therapy (Shapiro, 2018). This model emphasizes that
learning occurs as we assimilate new experiences into existing neurophysi-
ological memory networks. Pathology arises when memories of negative life
experiences are inadequately processed. Unprocessed memories are dys-
functionally stored and contain images, thoughts, emotions, and sensations

In memory of Francine Shapiro—­a brilliant clinician with theoretical foresight, who dedi-
cated her life to healing human suffering.

234
Eye Movement Desensitization and Reprocessing Therapy 235

that were experienced at the time of the adverse event. When triggered,
the unprocessed memories negatively influence perception, attitudes, and
behavior in the present. Recovery from PTSD with EMDR therapy occurs
through accessing dysfunctionally stored memories and the initiation of an
accelerated learning state via focused processing that integrates them into
adaptive memory networks. Understanding how memory processing occurs
in EMDR therapy largely stems from research that has examined the eye
movements (EMs) used during EMDR memory processing. Presently, more
than 30 RCTs and a meta-­analysis (Lee & Cuijpers, 2013) have demonstrated
that the EMs in EMDR therapy significantly add to its beneficial treatment
effects. Current explanations of mechanisms underlying EMDR therapy
include theories related to working memory, the orienting response, and
REM.
Working memory theory holds that components of working memory
have limited capacity (Baddeley, 2012). In EMDR therapy, engaging in EMs
or other dual-­attention stimuli such as bilateral taps or tones while focusing
on trauma-­related memories simultaneously taxes working memory, impair-
ing the ability to hold a visual image in awareness, which causes image quality
to deteriorate and the memory to be integrated in a less vivid and therefore
less emotional form (van den Hout et al., 2012). Orienting response theory
posits that EMs or other dual-­attention stimuli elicit an orienting response
with associated decreases in physiological arousal (i.e., de-­a rousal) that aids
memory processing (Landin-­Romero et al., 2013). An orienting response is
an autonomic, attentional reaction evoked by a new stimulus that is assessed
for threat (Bradley, 2009). Repeated presentation of nonthreatening stim-
uli leads to the orienting response quickly habituating and to physiological
de-­a rousal. Investigations of physiological correlates of the EMs in EMDR
therapy demonstrate the presence of orienting responses (Schubert et al.,
2016), de-­a rousal via increased parasympathetic tone during EM sets (Sack,
Hofmann, Wizelman, & Lempa, 2008), and physiological changes charac-
teristic of a REM-like state (Elofsson, von Scheele, Theorell, & Sondergaard,
2008). A third explanation of the underlying mechanism of EMDR therapy
derives from REM research and posits that EMs induce slow wave sleep and
REM-like neurobiological mechanisms, which facilitate integration and con-
solidation of episodic traumatic memories into semantic networks (Pagani
et al., 2007; Stickgold, 2002).
A comprehensive understanding of EMDR therapy requires consider-
ation of all three theories and how the mechanisms proposed may simul-
taneously contribute to the information processing seen in effective PTSD
treatment. Currently, these mechanisms appear consistent with neurobio-
logical theories of memory reconsolidation (Suzuki et al., 2004), which pro-
pose that a recalled memory is labile and can be linked to new and existing
adaptive information and then restored in an altered form. Recent research
has found that memory reconsolidation may be disrupted by a distractor
stimulus presented during reactivation (Crestani et al., 2015).
236 Treatments for Adults

In addition to theoretical accounts of how EMDR therapy processes

memory, there is evidence from neurophysiological research suggesting that
effective EMDR therapy results in repair of the structure and functioning
of areas within the brain that facilitate information processing and memory
integration (Landin-­Romero et al., 2013). For example, after the effective
EMDR treatment of patients diagnosed with PTSD, there have been reports
of increased hippocampal volume (Bossini et al., 2017), left amygdala volu-
metric increase (Laugharne et al., 2016), increased prefrontal cortex gray
matter (Boukezzi et al., 2017), and functional normalization in limbic struc-
tures implicated in PTSD (Lansing, Amen, Hanks, & Rudy, 2005; Oh &
Choi, 2004; Pagani et al., 2007, 2012). Using functional magnetic resonance
imaging (fMRI) techniques, EMDR therapy has been found to be associated
with increased activity in the left hippocampus and left amygdala (Rous-
seau et al., 2019). Recent investigation into the neural circuits underlying
EMDR therapy has demonstrated, through animal research, that alternate
bilateral visual stimulation suppresses fear (Baek et al., 2019). Baek and col-
leagues (2019) found evidence that lasting fear reduction occurred via a
neuronal pathway driven by the superior colliculus and supporting activity
in the mediodorsal thalamus and prefrontal cortex to compete with emo-
tional amygdala activity. This effect was not found for auditory or other
types of visual stimulation. Overall, continued research is needed to fully
understand the theory underlying EMDR therapy and the interrelationships
among different psychological, physiological, and neurological mechanisms
in EMDR treatment of PTSD.

Description of Techniques

EMDR therapy employs an eight-phase approach to address the full range of

clinical symptoms caused or exacerbated by past adverse experiences. The
phases include history taking; preparation; four reprocessing phases (assess-
ment, desensitization, installation, body scan); closure; and reevaluation.
EMDR therapy emphasizes working with imagery, cognitions, emotions,
somatic sensations, and behavior linked to the disturbing memory, as well
as attending to past, current, and future-­oriented experiential contributors.
The following is an overview of the main goals and procedural objectives of
the eight phases of EMDR therapy.

Phase I: Client History

Phase I comprises standard history taking, rapport building, and informed
consent. The clinician obtains background information and determines
client suitability for EMDR therapy. If treatment goals are PTSD symptom
reduction, the clinician identifies target memories that are not only “Criterion
A” trauma experiences related to emergence of the client’s major diagnostic
Eye Movement Desensitization and Reprocessing Therapy 237

presentation (DSM-5; American Psychiatric Association, 2013), but also

other associated memories of adverse life experiences that are hypothesized
to be driving and maintaining current trauma and associated symptoms.
Comprehensive EMDR treatment involves evaluation and remediation of the
client’s entire clinical picture, including emotional dysregulation, addressing
fears, anxieties and avoidance, negative self-­beliefs, problematic behaviors,
and attachment issues (Shapiro, 2018). The clinician identifies current prob-
lems and uses direct questioning and several techniques (e.g., “floatback,”
also known as “affect bridge”) to focus on current somatic and/or cognitive
responses in order to associate them with and identify unprocessed mem-
ories that are the foundation of the symptoms. For example, in an affect
bridge, the clinician instructs the client to “hold the experience in mind,
notice the emotions you’re having right now and notice what you’re feeling
in your body. Now let your mind scan back to an earlier time when you may
have felt this way before and just notice what comes to mind.”

Phase II: Client Preparation

The goal during this phase is to establish client readiness for EMDR therapy
by enhancing client trust and rapport, describing the therapy procedures,
explaining the theory, testing the eye movements or other type of bilateral
stimulation (BLS), teaching affect regulation techniques such as the “safe/
calm place,” which links a positive emotional state to a word or image, or
other methods for building affect tolerance and stability. An affect regula-
tion technique utilized in EMDR therapy preparation is resource develop-
ment and installation (RDI; Korn & Leeds, 2002). The aim is to identify and
enhance the client’s awareness of his or her strengths, qualities, and capaci-
ties, with the aim of increasing that individual’s ability to cope with over-
whelming specific daily situations and memory processing itself. For PTSD
resulting from a single traumatic event, which research has demonstrated
can be treated within three 90-minute sessions (Rothbaum, 1997; Wilson,
Becker, & Tinker, 1997), the history taking and preparation phases can be
completed in the first session. For multiple or childhood trauma histories,
the course of treatment may need to be 12, 90-minute sessions (Boterhoven
de Hann et al., 2017).

Phase III: Assessment

EMDR therapy does not require detailed self-­disclosure about traumatic
events. For example, those debilitated by shame or guilt, such as sexual
abuse survivors or combat veterans with a moral injury (i.e., Russell & Figley,
2013), can simply provide a general report of what occurred (e.g., “My step-
father molested me”). In this phase, the clinician asks the client to bring the
trauma to awareness, then select a representative image and present-­related
negative cognition (NC; e.g., “I’m dirty”), emotion(s), physical sensation(s),
238 Treatments for Adults

and body location. The clinician obtains a baseline Subjective Units of Dis-
tress Scale (SUDS) rating (Wolpe & Abrams, 1991), from 0, “no distress,”
to 10, “worst possible.” The clinician also elicits a preferred belief or posi-
tive cognition (PC)—an adaptive desired self-­statement related to the target
memory—­and a baseline rating for the desired PC on the Validity of Cogni-
tions (VoC) Scale, with 1 indicating “completely untrue” and 7 “completely
true.” Over the course of treatment, each target memory is assessed for key
memory components (e.g., the image, cognition and meaning, and emotion
and body sensation). Thus, the therapist asks in each case for a representa-
tive picture associated with the traumatic event, what the event means to the
person, and his or her emotions as reflected in feelings and body sensations.
Following desensitization of all trauma-­related memories, anticipated future
challenges are also assessed in this manner.

Phase IV: Desensitization

The goal of the desensitization phase is to process the maladaptively stored
memory and facilitate its full integration within adaptive memory networks.
To initiate EMDR therapy processing, a state of “dual-­focused attention” is
created by the therapist instructing clients to be aware of the target mem-
ory and its representative components (e.g., “Bring up that memory of the
motor vehicle accident,” the negative cognition, emotion, and physical sen-
sations), while simultaneously directing clients to engage in approximately
24 rhythmic sets of BLS (e.g., eye movements, tapping, auditory tones). It is
highly recommended that clinicians initially utilize eye movements for BLS
whenever possible (Shapiro, 2018), because over 30 trials have documented
the significant positive effects of eye movements in decreasing arousal and
memory vividness and/or negative affect (see Lee & Cuijpers, 2013, for a
review), increased recognition of true information (Parker, Buckley, & Dag-
nall, 2009), retrieval of episodic memory (Christman, Garvey, Propper, &
Phaneuf, 2003), and attentional flexibility (Kuiken, Bears, Miall, & Smith,
2002). During BLS, the therapist may encourage the client, making state-
ments like “Just let whatever happens, happen” and “Simply notice what
occurs.” The amount of therapist verbal interaction during EMDR therapy
processing is dependent on the client’s need for support (e.g., “It’s in the
past, just notice it”). At the end of each set of BLS, clients are asked, “What
do you notice now?” If the client indicates progress in memory processing
(e.g., “It’s fading,” “It switched to another memory”), the therapist initiates
further BLS with simple prompts, for instance, “Just stay with that.”
In contrast to exposure-­based models, the client describing a new nega-
tive memory during EMDR therapy is generally considered an example of
associated experiences with the targeted event rather than an avoidance of
trauma processing. Research demonstrates that in EMDR therapy, responses
indicating distancing from the memory, as opposed to reliving responses,
are an indication of effective EMDR memory processing (Lee, Taylor, &
Eye Movement Desensitization and Reprocessing Therapy 239

Drummond, 2006). It is important for clinicians to trust the innate adaptive

information processing and avoid detailed questioning between BLS sets. In
effect, EMDR therapy processing involves following the client’s spontaneous
associations, coupled with BLS sets until no further change in self-­report or
desensitization occurs (e.g., SUDS ratings of 0–1). If the client is unable to
utilize EMs during BLS, then clinicians should offer either tapping or audi-
tory tones and evaluate their effectiveness.
If processing appears to be “blocked,” suggested by no cognitive or
somatic changes after two sets of BLS, therapists use various brief interven-
tions, such as a change in direction of eye movements (e.g., vertical vs. diago-
nal), alternating speed of BLS (faster vs. slower), or directing attention to a
specific aspect of the trauma experience (e.g., “Notice the tightness in your
jaw”), followed immediately by a BLS set (Shapiro, 2018). On occasion, when
a client becomes “stuck” (e.g., fails to report a change in SUDS or cogni-
tion after two or more consecutive BLS sets, even after the aforementioned
adjustment), the therapist may inject a “cognitive interweave,” which is a
succinct statement or question aimed at eliciting a new adaptive perspective,
thought, action, or image (e.g., “Who was responsible for what happened?”).
The clinician instructs clients to notice what happens next (e.g., in terms of
images, thoughts, feelings, and body sensations) while they focus on their
response to the interweave and the therapist initiates another set of BLS.
Use of cognitive interweaves or other additions from the standard EMDR
therapy protocol should be minimal. Such interventions are viewed as dis-
rupting memory processing by imposing therapist-­driven solutions to the
issues that might otherwise be achieved by allowing the client’s own idiosyn-
cratic, innate adaptive processing to occur.
Processing generally entails simultaneous shifts in affective, cognitive,
and somatic components of the memory, and shifts to alternative but associ-
ated memory networks. Clinical effects during this phase are measured using
SUDS ratings of the target memory. Typically, as SUDS ratings decrease, the
content of client self-­reports increasingly and spontaneously includes more
positive or adaptive information. When the SUDS rating reaches 0 or 1 on
a target memory, the desensitization phase is concluded. Commonly, other
associated memories have been activated during processing and may also
have desensitized to some extent. However, this is not always the case. In
simpler cases, the clinician moves to the installation phase after desensitiza-
tion. For clients with multiple traumas, the clinician may instead reassess the
degree of distress associated with other related memories and, if they have
not desensitized, target these first before attempting integration.

Phase V: Installation
After desensitization appears complete, the adaptive PC associated with
the target memory is paired with BLS sets until a VoC of 6–7 is achieved.
Additional processing in this phase addresses any residual disturbances,
240 Treatments for Adults

strengthens the connection with currently existing positive memory net-

works, and facilitates generalization effects. It should be noted that the tar-
get SUDS and VoC numbers are guidelines and that other clinical indicators
of progress, such as the elicitation of insights (e.g., the trauma is over, they
survived, they can see themselves as safe, supported, and able to manage in
the future), are also employed (Shapiro, 2018).

Phase VI: Body Scan

The client focuses on the target memory and searches for negative physical
sensations that, if present, are processed with BLS sets until absent. This
provides a check for aspects of the traumatic memory that were not fully
processed.

Phase VII: Closure

When processing is incomplete, the therapist may utilize relaxation tech-
niques like safe/calm place to stabilize the client if necessary. When process-
ing appears complete, there can be more extensive therapeutic discussion—­
for example, discussion on the insights that arose during processing and the
effect processing may have on current symptoms, particularly those of an
avoidance and intrusive nature. Clients are educated about what to expect
following desensitization and asked to briefly indicate any between-­session
disturbance in a “TICES” log, which contains columns to note the trigger,
image, cognition, emotion, and physical sensation/SUDS (Shapiro, 2018).
They are also instructed to utilize self-­calming procedures taught during
Phase II.

Phase VIII: Reevaluation

Multiple phases can be completed within a single session. However, at the
beginning of the next session, the clinician reevaluates the target memory
and TICES log. If the past memories are adequately processed, the clinician
can proceed to present triggers, then future templates. Present triggers are
typically recent events that triggered distress since the last session. If such an
event has occurred, the client is asked to focus on this recent incident (e.g.,
“I saw a guy in a red sweatsuit similar to the one worn by the person who
assaulted me”) and associated negative cognition and feelings. The therapist
next engages the client in processing using Phases IV–VII. The future tem-
plate involves imagining future events that might give rise to distress, target-
ing the reduction of the associated arousal, and then in the imagination,
rehearsing more adaptive behaviors and associated ideas.
Additional reevaluation sessions can be scheduled at staggered inter-
vals if clinically indicated or practical, to determine the stability of symp-
tom change over a longer period of time. To complete the standard EMDR
Eye Movement Desensitization and Reprocessing Therapy 241

therapy protocol, clinicians must complete the three-­ pronged protocol,

which includes reprocessing memories of the past adverse events, process-
ing current triggers, and incorporating “future templates.”

Summary and Appraisal of the Evidence

In the 30 years since Shapiro (1989) first described EMDR therapy, there
have been over 30 RCTs testing the treatment’s efficacy with adults with
PTSD, nine RCTs testing its efficacy in treating children with full or partial
PTSD, and seven RCTs assessing its efficacy for people recently exposed to a
traumatic experience. The cumulative evidence from RCTs led the Interna-
tional Society for Traumatic Stress Studies (ISTSS) guidelines to give EMDR
therapy a Strong recommendation for the treatment of adults and children
with PTSD. This is consistent with other treatment guidelines, such as those
published by the World Health Organization (2018) and the Australian Cen-
tre for Posttraumatic Mental Health (2013). In this chapter, we provide a
summary of the evidence for adults with PTSD. The evidence with respect
to treating children is covered by Olff and colleagues and Jensen, Cohen,
Jaycox, and Rosner (Chapters 11 and 21, respectively, this volume) and in
Chen and colleagues’ review (2018), and the evidence of effectiveness for
treating recent trauma survivors is described by O’Donnell, Pacella, Bryant,
Olff, and Forbes (Chapter 8, this volume).
In reviewing the evidence on the treatment of adults, the ISTSS guide-
lines identified 11 RCTs where EMDR therapy was compared to a wait-list or
treatment as usual (TAU) control. In the meta-­analyses, EMDR therapy was
found to have a significant positive effect compared with these conditions,
and this effect size was large (standardized mean difference [SMD] = 1.24).
Once two studies with subclinical dosages were removed, the effect size was
even larger (SMD = 1.40).
In addition, a larger number of trials (17) were identified that compared
EMDR therapy to another active treatment. The comparisons included
cognitive-­behavioral therapies (CBT) (Capezzani et al., 2013; Devilly &
Spence, 1999; Devilly, Spence, & Rapee, 1999; Ironson, Freud, Strauss, &
Williams, 2002; Laugharne et al., 2016; Lee, Gavriel, Drummond, Richards,
& Greenwald, 2002; Nijdam, Gersons, Reitsma, de Jongh, & Olff, 2012; Power
et al., 2002; Rothbam, Astin, & Marsteller, 2005; Taylor, 2003; Vaughan et
al., 1994), supportive counseling (Scheck, Schaeffer, & Gillette, 1998), and
relaxation (Carletto et al., 2016; Carlson, Chemtob, Rusnack, Hedlund, &
Muraoka, 1998; Taylor, 2003; Vaughan et al., 1994). There are other relevant
RCTs that did not meet the ISTSS inclusion criteria, such as the comparison
of EMDR therapy to CBT and a wait-list control for patients with a dual diag-
nosis of PTSD and psychosis (van den Berg et al., 2015), and when EMDR
therapy was compared to a placebo control and fluoxetine (van der Kolk et
al., 2007).
242 Treatments for Adults

These RCTs investigated the effects of EMDR therapy on a variety of

different trauma exposures, including refugees from war zones (Acarturk
et al., 2016; Ter Heide, Mooren, van de Schoot, de Jongh, & Kleber, 2016),
motor-­vehicle accidents (Aldahadha, Harthy, & Sulaiman, 2012), diagnosis
of a life-­t hreatening condition (Capezzani et al., 2013; Carletto et al., 2016),
military veterans (Carlson et al., 1998; Himmerich et al., 2016; Jensen, 1994),
childhood sexual abuse (Edmond, Rubin, & Wambach, 1999), mixed trauma
populations (Laugharne et al., 2016; Lee et al., 2002; Taylor, 2003; van der
Kolk et al., 2007), sexual or physical assault (Nijdam et al., 2012), sexual
assault (Rothbam et al., 2005), and childhood physical or emotional abuse
(Scheck et al., 1998). Thus, the ISTSS guidelines’ Strong recommendation for
the use of EMDR therapy is based on robust findings indicating that EMDR
therapy is applicable to a wide range of trauma populations, and its effective-
ness is generalizable across contexts and cultures.
Treatment gains following EMDR therapy are substantial and stable.
Loss of PTSD diagnosis ranges from 48% (Vaughan et al., 1994) to 94–95%
(Capezzani et al., 2013; Nijdam et al., 2012). Moreover, gains in symptom
reduction for trauma-­related symptoms, depression, and anxiety at posttreat-
ment have been found to be sustained at 18-month follow-­up for survivors
of childhood sexual abuse treated with EMDR therapy (Edmond & Rubin,
2004). Similarly, trauma-­related symptom reduction and improvements in
secondary measures after treatment were maintained at 35 months follow-­up
for a group of Swedish transport workers with chronic PTSD (Högberg et al.,
2008).
EMDR therapy is also effective when there are comorbid symptoms. In a
meta-­analysis of PTSD treatment studies (Chen et al., 2014), EMDR therapy
was found to lead to large reductions (g = 0.64) for both depression and anxi-
ety compared with inactive and active controls. Subgroup analyses indicated
that the duration of the treatment sessions affected these outcomes, such
that sessions longer than 60 minutes led to larger reductions in depression
and anxiety. Another meta-­analysis investigating the effectiveness of EMDR
therapy compared to trauma-­focused CBT on depressive symptoms when
comorbid with a PTSD presentation found a similar large (g = 0.63) effect
size (Ho & Lee, 2012).
EMDR therapy has been identified as an efficient and effective treat-
ment for adults who experienced childhood sexual trauma and adult-onset
sexual assault, beginning with an RCT indicating 90% elimination of PTSD
in rape victims after three 90-minute sessions (Rothbaum, 1997). Rothbaum
and colleagues (2005) also conducted a head-to-head comparison between
EMDR therapy and prolonged exposure with adult sexual assault survivors.
Although both treatments resulted in significant improvements compared
to a wait-list control, there were no differences between the treatments. How-
ever, “an interesting potential clinical implication is that EMDR seemed to
do equally well in the main despite less exposure and no homework” (p. 614).
An encouraging finding from RCTs examining EMDR therapy to date
is that it can relieve trauma-­ related symptoms in populations of severe
Eye Movement Desensitization and Reprocessing Therapy 243

interpersonal trauma and in treatment settings other than a traditional

office. For example, therapists working inside a refugee camp with people
who had fled a military conflict were able to achieve significant improve-
ments compared to a wait-list control, and treatment gains were maintained
at follow-­up despite participants living in ongoing unstable conditions (Acar-
turk et al., 2016). Similar effect sizes were reported when treating survivors
of the Timorese war (Schubert et al., 2016). After a mean of four sessions,
95% no longer met PTSD criteria. Also, women with acting-­out behaviors
and referred mainly from forensic settings did significantly better after
receiving only two sessions of EMDR therapy compared to active listen-
ing on measures of trauma symptomology and depression, bringing scores
within 1 standard deviation of the norm (Scheck et al., 1998).

Practical Delivery Recommendations

Optimal Delivery of EMDR Therapy
A review of the efficacy research on EMDR therapy indicates that optimal
delivery is over approximately 4.5 hours of treatment in sessions of 60–90
minutes for comprehensive treatment of PTSD resulting from a single
trauma (e.g., Marcus, Marquis, & Sakai, 1997, 2004; Rothbaum, 1997; Wil-
son, Becker, & Tinker, 1995; Wilson et al., 1997). PTSD resulting from mul-
tiple traumas may require longer treatment. For example, 12, 90-minute ses-
sions in the case of combat veterans (Carlson et al., 1998) and for adults with
PTSD from childhood experiences may be needed (Boterhoven de Haan et
al., 2017). As indicated in the World Health Organization’s (2018) practice
guidelines, EMDR does not involve: “(a) detailed descriptions of the trau-
matic event(s), (b) direct challenging of beliefs, (c) extended exposure, or
(d) homework” (p. 1).
The standard EMDR therapy protocol is optimal when unimpeded
processing occurs. However, when processing gets stuck, as may happen in
the case of excessive shame, survivor guilt, or moral injury, then cognitive
interweaves can be used by instructing clients to contemplate some miss-
ing adaptive information (e.g., “What would you think if it had happened
to your son?” or “Did you do what you were trained to do?”) while paired
with BLS (“Just think of that and follow my hand”). Targets for processing
also include flashback scenes and nightmares, which generally rapidly remit,
often revealing and resolving the underlying cause.

Special Populations
Complex Traumatic Events
For those who have suffered severe, chronic exposure to adverse child-
hood events, clinicians should ensure that clients have sufficient capacity to
access past traumatic memories, while remaining stabilized in the present.
244 Treatments for Adults

Consequently, it is considered best to extend the preparation phase to ensure

a client’s ability to safely tolerate the emotional distress associated with
accessing traumatic experiences. This can be accomplished by stabilization
interventions such as resource developmental and installation (RDI; Korn &
Leeds, 2002), which increases the client’s access to positive emotional states
(e.g., confidence). For those with multiple, complex trauma histories, the
EMDR therapy protocol, which engages the client in unrestricted memory
processing, can be adjusted to the initially developed EMD (Shapiro, 1989),
which minimizes client associations by focusing on present disturbance or
triggers. When containing memory processing in this way, the therapist
plans with the client to focus on a defined memory target and restrict associ-
ated processing. When adequately prepared (i.e., the client is able to remain
present without dissociating or experiencing incapacitating distress), EMDR
processing should address the full range of adverse life experiences, includ-
ing childhood events. During processing, clinicians are advised to (1) tar-
get the client’s somatic and verbal responses with BLS, (2) frequently assess
for hyper- and hypo-­a rousal, especially dissociation, and (3) be prepared to
utilize EMDR strategies like the cognitive interweave for blocked process-
ing, while (4) regularly reassuring clients, “It’s old stuff, you are in control
and I’m here with you.” Current research is investigating the possibility that
clients with such traumatic experiences can, in fact, benefit from EMDR
therapy without stabilization (Boterhoven de Hann et al., 2017). However,
multiple rigorous RCTs providing sufficient treatment time are needed to
adequately address this issue.
Another clinical feature of EMDR therapy is the possibility of process-
ing trauma material without the need for detailed information. Clinicians
can focus on processing the emotional, cognitive, and somatic (e.g., pain)
representations of the traumatic experiences when minimal perceptual
details of the event are recalled. For some clients, this has an advantage as
he or she can process the trauma without having to disclose details of events.

Children
EMDR therapy has been used with children as young as 1 year old, with
limited cognitive capacities or developmental delays, who may find extended
exposure overwhelming; live in complex, chaotic family systems; and are
unable to engage in therapeutic homework tasks. Contraindications for use
of EMDR therapy with children include situations where they are actively
being abused or exposed to ongoing threats to their safety. The full eight
phases and three-­ pronged protocol are employed. However, significant
variations are introduced to hold the attention of young children, such as
the therapist using glove puppets in each hand and focusing each child’s
attention on these to facilitate bilateral eye movements (Adler-Tapia & Settle,
2017). Adaptations to the EMDR therapy protocol include ensuring develop-
mentally appropriate language is used throughout all phases of treatment.
Eye Movement Desensitization and Reprocessing Therapy 245

For example, in taking a history, clients are helped to tell their story and
identify target memories in developmentally appropriate ways (e.g., maps,
timelines, storybooks). In the target assessment phase, the positive and nega-
tive beliefs associated with trauma experiences may be event-­specific, rooted
in the present tense, and use feeling-­based words. Child-­friendly adaptations
of the VoC and SUD scales (e.g., pictures) are also used. During processing,
various BLS tasks are employed to maintain attention (e.g., tapping, drum-
ming). For children with complex trauma presentations and attachment
issues, EMDR therapy is effective with appropriate protocol modifications
(e.g., Gomez, 2013; Wesselmann, Schweitzer, & Armstrong, 2014).
When EMDR therapy is utilized in creative, flexible, and playful ways,
children, even those with multiple trauma histories and complex trauma
presentations, are able to fully engage in processing sessions. For example,
the EMDR clinician adjusts communication and language to match a child’s
developmental level. The clinician may vary methods of BLS and keep things
playful so the child remains engaged in the therapy. Children may require
shorter sets and may need more breaks in reprocessing. Children may be
encouraged to express themselves through play and artwork during the
assessment phases. The inclusion of parents may be critical to understand-
ing the child’s history, and parents might help provide emotional support as
needed during the desensitization phases. The integration of family therapy
may interrupt negative dynamics in the home and create a more positive and
supportive atmosphere for the child’s recovery.

Military Veterans
Although EMDR research has demonstrated its usefulness across a variety
of military clinical and operational settings (Carlson et al., 1998; Hurley,
2018), the clinician needs to consider therapy targets with flexibility to a cli-
ent’s issues. The possible foci of the therapy include traumatic grief, moral
injury, posttraumatic anger, survivor guilt, medically unexplained physical
symptoms, phantom limb pain (PLP), and intense betrayal resulting from
military sexual trauma (see Russell & Figley, 2013). Moral injury is a con-
struct that describes extreme and unprecedented life experiences, including
the harmful aftermath of exposure to such events. Events are considered
morally injurious if they transgress deeply held moral beliefs and expecta-
tions (Litz et al., 2009).
In each scenario, the client’s self-­reports of anger, betrayal, guilt, shame,
grief, somatic symptoms, or PLP are paired with BLS, along with associated
cognitions, memories, emotions, and physical sensations. When process-
ing becomes stuck, then brief therapist-­induced interventions like cognitive
interweaves are introduced.
Complicating issues can arise with military populations who may expe-
rience blocked processing due to deep-­seated fears that positive therapeutic
change may deprive them of remembering their fallen comrades, or because
246 Treatments for Adults

they view their suffering as just punishment for their perceived or actual
moral failings (e.g., participating in an atrocity). In some cases, veterans will
directly state their ambivalence toward change. In others, the therapist may
have to probe for underlying beliefs that block processing, and/or interject
cognitive interweaves (e.g., “What would your buddy say?”). Once uncov-
ered, the client’s expressed fears or concerns and related associations are
processed with BLS.
Comprehensive trauma-­focused treatment of military personnel often
goes beyond PTSD diagnosis to include physical symptoms, such as chronic
pain including, but not limited to, PLP, which has generally been viewed
as an intractable condition. However, EMDR therapy holds that the pain is
caused by the unprocessed memory of the injury that, as indicated in the
AIP model, contains the somatic sensations and emotions experienced at
the time of the event. Successful EMDR treatment of PLP has been reported
over the past decade subsequent to processing pivotal memories (e.g., Rus-
sell, 2008; Schneider, Hofmann, Rost, & Shapiro, 2008). Recently, an RCT
(Rostaminejad, Behnammoghadam, Rostaminejad, Behnammoghadam,
& Bashti, 2017) found that EMDR therapy significantly reduced PLP and
related psychological symptoms through processing the disturbing memo-
ries. All participants reported pain reduction, with 47% claiming to be pain-
free. Treatment gains were maintained at 2-year follow-­up.

Disaster Survivors
EMDR therapy has been recognized by the international community as a
front-line recommended treatment for disaster-­related PTSD (e.g., World
Health Organization, 2018). Several recent protocols have been developed
to help survivors at the time of the event, within 2–3 months, and within
6 months, even while being continuously exposed to trauma (see Shapiro,
2018). Randomized trials have demonstrated the effectiveness of natural and
man-made postdisaster protocols in adults (e.g., Acarturk et al., 2016) and
children (e.g., Chemtob, Nakashima, & Carlson, 2002; de Roos et al., 2011).
In a postdisaster context, clinical and practical concerns lead to EMDR ther-
apy being delivered daily or biweekly, as opposed to weekly (Acarturk et al.,
2016; Schubert et al., 2016). Also, in large-scale postdisaster contexts where
clinical resources may be limited, an integrative group EMDR therapy proto-
col can be utilized to process memories of trauma experiences and identify
those who may require further individualized EMDR therapy (Jarero, Arti-
gas, & Hartung, 2006).

Limitations of EMDR Therapy

Clients with a seizure disorder, acute traumatic brain injury, or compli-

cated pregnancy are not suitable for EMDR therapy until appropriate safety
Eye Movement Desensitization and Reprocessing Therapy 247

concerns are cleared. Moreover, although no two clients are identical in their
response to EMDR therapy, changes in perceptual detail, cognitions, physio-
logical and emotional responses to traumatic experiences are common (e.g.,
Shapiro, 2018). Therefore, clinicians should be wary of using EMDR therapy
in legal cases without prior consultation with an attorney if the preservation
of unaltered, vivid recollections of witnesses is essential.
In addition, trauma survivors may be averse to the potential of recall-
ing earlier traumatic or adverse events warranting appropriate informed
consent that EMDR therapy effects may generalize beyond the present inci-
dent (see Shapiro, 2018). However, another significant challenge in utilizing
EMDR therapy lies within the therapist. Specifically, clinicians experienced
in providing mainstream psychotherapies that involve a great deal of thera-
pist probing, reframing, and interpretation may experience some difficulty
shifting gears to properly apply EMDR therapy. That said, clients who enter
therapy expecting extensive dialogue from a probing therapist, and/or who
desire detailed discussion of their traumatic memories and the processing
thereof, can become irritated with the EMDR clinician’s repeated refrain:
“Just think of that . . . and follow my hand” or whatever BLS is utilized.
Therapists should be aware of this possibility and be able to adjust accord-
ingly. Additional challenges in utilizing EMDR therapy include securing cli-
ent buy-in due to its unorthodox procedural framework (i.e., EM and other
BLS). In short, EMDR therapy is not a panacea and will not be a good fit for
every client and/or therapist.
An issue in treating more complex trauma presentations is that once
the trauma memories have been desensitized, the person may indeed no lon-
ger have PTSD symptoms but retain disturbances in interpersonal relation-
ships. EMDR therapy on its own cannot fix the skills deficits that a lifetime
of trauma or trauma activation has had on a person’s functioning. Once
the person no longer exhibits PTSD symptoms, therapy for this population
needs to focus on providing skills and coaching in behaviors to be better
equipped to facilitate growth.
Finally, personality variables may affect how EMDR therapy is received.
The treatment requires clients to focus on just noticing what occurs, with-
out judging their experience. However, this might be difficult for clients
who score low on traits such as openness to new experience, which research
has demonstrated reduces the efficacy of other trauma treatments (van
Emmerik, Kamphuis, Noordhof, & Emmelkamp, 2011).

Future Developments

Rigorous research is needed to further our understanding of the crucial

processes in EMDR therapy and to test adaptations of the standard protocol
and how EMDR therapy can be extended to special populations. An inter-
esting format issue includes frequency of sessions. Is EMDR therapy best
248 Treatments for Adults

delivered every day, twice a week, or once a fortnight? In addition, prelimi-

nary findings suggest EMDR therapy can be provided in a group format for
those who have acutely suffered trauma, but will such treatment protocols
prove effective in other studies? To what extent does cultural context impact
treatment effectiveness? Culture may affect how a trauma-­focused treatment
is received, and trauma may impact culture. The ability of people plagued
by ethnopolitical violence to reconcile with each other is often thwarted by
unprocessed traumatic memories. One reason for this is the presence of
a negative attentional bias that can occur in individuals with PTSD (e.g.,
Pineles, Shipherd, Mostoufi, Abramovitz, & Yovel, 2009) and hamper their
ability to disengage from threatening cues. This can inhibit the ability of
historically feuding people, the very sight of whom may cause intractable
resistance, to forge agreement. Fortunately, preliminary research suggests
that disruptive attentional biases can be ameliorated by EMDR therapy (El
Khoury-­Malhame et al., 2011). More research is needed to confirm this
observation, especially studies that focus on ways to facilitate mediation and
reconciliation.
Given the recent inclusion of complex PTSD in the International Classi-
fication of Diseases, 11th revision (ICD-11; World Health Organization, 2018),
RCTs examining efficacy and effectiveness are needed for this population
group. Ongoing research is required to understand the optimal stabilization
required for effective trauma memory processing in complex PTSD popula-
tions, and how to most efficiently attain stability prior to memory process-
ing, and to effectively maintain it during and between processing sessions.
Further efforts are also required to understand the tolerability of treatment
and dropout rates observed in complex PTSD populations (Boterhoven de
Haan et al., 2017). In addition, there are a host of other empirical studies
yet to be undertaken with EMDR therapy, including the combined effects of
using multiple types of BLS simultaneously, and the effectiveness of EMDR
therapy in treating co-­occurring conditions, such as moral injury, compli-
cated grief, chronic mild traumatic brain injury, substance abuse, and pain
disorders.
In summary, EMDR therapy was introduced three decades ago (Shap-
iro, 1989). The accumulated literature provides evidence that EMDR ther-
apy is an effective treatment for PTSD and trauma-­related conditions arising
from different types of traumas, in different contexts and cultures. Encour-
agingly, the evidence supports its use in interpersonal and simple traumas,
for both adults and children, and for chronic and recent trauma events. Fur-
ther understanding the underlying mechanisms and its limitations requires
additional research. Research into the mechanisms of EMDR therapy has to
date challenged existing contemporary theories of PTSD and has advanced
our understanding of the development and recovery from PTSD. However,
there is still much to learn in terms of understanding what constitutes best
practice for individuals with complex PTSD and comorbid presentations.
Eye Movement Desensitization and Reprocessing Therapy 249

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C H A P TE R 15

Cognitive Therapy
Anke Ehlers

O ne of the basic ideas of cognitive therapy is that clients’ symptoms and

behavior make sense if one understands how they perceive themselves
and the world, and what they make of these perceptions. To help clients
change unhelpful cognitions that contribute to their symptoms and behav-
ior, therapists need to “get into their clients’ heads,” that is, understand how
they perceive and interpret the surrounding world, what they think about
themselves, and what beliefs motivate their behavior.
Traumatic events are extremely negative events that everyone would
find highly threatening and distressing. Yet what people find most distressing
about a traumatic event, and what it means to them, varies greatly from per-
son to person, and influences the probability of developing posttraumatic
stress disorder (PTSD). Cognitive therapy for PTSD (CT-PTSD) addresses
threatening personal meanings of trauma, together with characteristics of
trauma memories and unhelpful coping strategies. This chapter describes
the treatment procedures used in CT-PTSD and the theory behind them,
reviews the evidence collected so far, and discusses the implementation of
CT-PTSD in clinical practice, before outlining areas for future development.

Theoretical Background

Ehlers and Clark’s (2000) cognitive model of PTSD was developed to explain
why some people do not recover from traumatic events and develop chronic
PTSD, and to serve as the framework for an individualized formulation of
a client’s problems and treatment. The model suggests that PTSD develops
if individuals process traumatic experiences in a way that produces a sense
of a serious current threat, which is driven, in turn, by two key processes (see
Figure 15.1).

255
256 Treatments for Adults

Trauma memory Appraisals of trauma

and/or sequelae
elaborate
Identify and modify

Triggers
discriminate

Current threat
Intrusions
Arousal
Strong emotions
reduce

Dysfunctional behaviors/cognitive strategies give up

FIGURE 15.1. Treatment goals in cognitive therapy for PTSD (Ehlers & Clark, 2000).
Pointed arrow heads indicate “leads to.” Round arrow heads indicate “prevents a
change in.” Dashed arrows indicate “influences.” From Ehlers (2013). Copyright ©
2013 John Wiley & Sons. Reprinted with permission.

The first source of current threat are negative appraisals (personal

meanings) of the trauma and/or its sequelae (e.g., reactions of other peo-
ple, initial PTSD symptoms, physical consequences of the trauma) that go
beyond what anyone would find threatening/horrific about the event. The
perceived threat can be external or internal, and the type of negative emo-
tion depends on the type of appraisal. Perceived external threat can result
from appraisals about impending danger (e.g., “I cannot trust anyone”),
leading to excessive fear, or appraisals about the unfairness of the trauma
or its aftermath (e.g., “I will never be able to accept that the perpetrator
got away with it”), leading to persistent anger. Perceived internal threat
often relates to negative appraisals of one’s behavior, emotions, or reactions
during the trauma or to the perpetrators’ or other people’s humiliating
or derogatory statements, and may lead to guilt (e.g., “It was my fault”) or
shame (e.g., “I am a bad person”). A common negative appraisal of con-
sequences of the trauma in PTSD is perceived permanent change of the
self or one’s life (e.g., “I have permanently changed for the worse”), which
can lead to sadness and hopelessness. In the case of multiply traumatized
individuals, personal meanings tend to become more generalized (e.g., “I
do not matter”; “I deserve bad things happening to me”; “I am worthless”),
Cognitive Therapy 257

leading to an enduring sense of degradation, defeat, or low self-worth. The

appraisals can become more embedded in a person’s belief systems over
time. For example, if an early life trauma has led a person to feel that he or
she is damaged in some way, or unlucky in life, experiencing further trauma
is likely to confirm this belief.
The second source of perceived current threat according to Ehlers and
Clark (2000) are characteristics of trauma memories. The worst moments of the
trauma are poorly elaborated in memory, that is, inadequately integrated
into their context (both within the event, and within the context of previous
and subsequent experiences/information). The effect of this is that people
with PTSD remember the trauma in a disjointed way. When they recall the
worst moments, it may be difficult for them to access other information
that could correct impressions they had or predictions they made at the
time: in other words, the memory for these moments has not been updated
with what the individuals know now, and the threat they experienced dur-
ing these moments is reexperienced as if it were happening right now rather
than being a memory from the past.
Ehlers and Clark (2000) also noted that intrusive trauma memories
are easily triggered in PTSD by sensory cues that overlap perceptually with
those occurring during trauma (e.g., a similar sound, color, smell, shape,
movement, or bodily sensation). They suggested that people during trauma
mainly process perceptual features of the experience, and that two basic
learning mechanisms, perceptual priming and generalized associative learn-
ing, lead to a poor discrimination of the stimuli in the current environment
from those in the trauma. This means that perceptually similar stimuli are
easily spotted and can trigger reexperiencing symptoms.
The problem is maintained by cognitive strategies and behaviors that peo-
ple with PTSD use to reduce the sense of current threat. These strategies
(such as effortful suppression of memories, rumination, excessive precau-
tions to prevent future trauma or “safety behaviors,” alcohol or drug use)
maintain PTSD by preventing change in the appraisals or trauma memory,
and/or by increasing symptoms—­and thus keep the sense of a current threat
going.
Figure 15.1 illustrates the three factors (appraisals, memory characteris-
tics, cognitive/behavioral strategies) that maintain a sense of current threat
and PTSD symptoms according to Ehlers and Clark’s (2000) model. CT-
PTSD targets these three factors. The model suggests three treatment goals:

• To modify excessively negative appraisals (meanings) of the trauma

and its sequelae
• To reduce reexperiencing by elaboration of the trauma memories
and discrimination of triggers
• To reduce behaviors and cognitive strategies that maintain the sense
of current threat
258 Treatments for Adults

Treatment Approach and Core Techniques

In common with other forms of cognitive therapy, CT-PTSD uses guided

discovery as the primary therapeutic style. As the main focus of the interven-
tion is the cognitions that stem from the traumas and induce a sense of cur-
rent threat, strategies such as Socratic questioning aim to gently guide cli-
ents to explore and examine a wider range of evidence by asking questions
that help them consider the problem from different perspectives, with the
aim of generating a less threatening alternative interpretation. The therapist
works from a perspective of curiosity, rather than trying to undermine or
prove the client’s perspective wrong. A nonthreatening, collaborative style of
interaction and establishing a good therapeutic relationship are essential to
working with trauma survivors.
Core interventions in CT-PTSD are:

• The therapist and client collaboratively develop an individualized case

formulation that is an individualized version of Ehlers and Clark’s (2000)
model of PTSD, which serves as the framework for therapy. Treatment pro-
cedures are tailored to the formulation.
• Reclaiming/rebuilding your life assignments are designed from the first
session onward to address the clients’ perceived permanent change after
trauma and involve reclaiming or rebuilding activities and social contacts.
• Changing problematic appraisals of the traumas and their sequelae (e.g.,
responses of others, physical consequences, symptoms of PTSD) involves
information, guided discovery, and behavioral experiments throughout treat-
ment. For appraisals of the traumas, this is closely integrated with the updat-
ing memories procedure.
• Updating trauma memories is a three-step procedure that includes
(1) accessing memories of the worst moments during the traumatic events
and their currently threatening meanings, (2) identifying information that
updates these meanings (either information from the course of events dur-
ing the trauma or from guided discovery and testing of predictions), and
(3) linking the new meanings to the worst moments in memory (see a more
detailed description later).
• Discrimination training with triggers of reexperiencing involves systemati-
cally spotting idiosyncratic triggers (often subtle sensory cues) and learning
to discriminate between “now” (cues in a new safe context) and “then” (cues
in the traumatic event) (see a more detailed description later).
• A site visit completes the memory updating and trigger discrimina-
tion (see Murray, Merritt, & Grey, 2015, for a detailed description).
• Dropping unhelpful behaviors and cognitive processes commonly includes
discussing their advantages and disadvantages and behavioral experiments,
Cognitive Therapy 259

whereby the patient experiments with reducing unhelpful strategies such as

rumination, hypervigilance for threat, thought suppression, and excessive
precautions (safety behaviors).
• A blueprint summarizes what the client has learned in treatment and
includes plans for any setbacks.

Throughout treatment, the work on appraisals is closely interwoven with

memory work and is tailored to the case formulation. The specific cognitive
therapy techniques depend on the client’s pattern of emotions and underly-
ing cognitive themes: for clients with an overgeneralized sense of risk, behav-
ioral experiments that test their predictions of impending harm (e.g., “I will be
attacked again”) are essential. For clients who are ashamed about what they
did or did not do during the trauma, surveys to discover other people’s views and
compare them with the reactions they anticipated (e.g., “People will think I
am weak and pathetic”) are very helpful. If clients blame themselves for the
trauma, treatment involves guided discovery of the contribution of other
people and situational factors to the event, which are then summarized in
a pie chart. For clients who are preoccupied with the injustice of the event,
writing a letter (which is usually not sent) expressing the effect the trauma
has had on their lives and expressing their anger is helpful, as well as a cost–­
benefit analysis of the advantages and disadvantages of staying angry.
Some of the behavioral and cognitive techniques used in other cognitive-­
behavioral therapy (CBT) treatments for PTSD are not used in CT-PTSD,
such as repeated exposures to promote habituation and exposure hierar-
chies (the updating memories and trigger discrimination procedures are
used instead), anxiety ratings in feared situations (Subjective Units of Dis-
tress/Discomfort Scale [SUDS]; the degree of conviction in appraisals and
nowness of memories are rated instead), or thought records or rehearsal of
rational responses (self-­instruction).

Summary and Appraisal of the Evidence

Four cognitive therapy studies with a total of 189 participants were included
in the evidence review for the prevention and treatment of PTSD guidelines
developed by the International Society for Traumatic Stress Studies (ISTSS)
and resulted in cognitive therapy receiving a Strong recommendation. These
studies compared it with a wait-list/repeated-­ assessment control group
(Duffy, Gillespie, & Clark, 2007; Ehlers, Clark, Hackmann, McManus, & Fen-
nell, 2005; Ehlers et al., 2003, 2014) and with an emotion-­focused supportive
counseling group (Ehlers et al., 2014). All four of the studies were conducted
in the United Kingdom. The results of the meta-­analysis indicated that cog-
nitive therapy showed a positive effect when compared with wait list or treat-
ment as usual (TAU) and in comparison with emotion-­focused supportive
260 Treatments for Adults

counseling, suggesting specificity of treatment effects. There has not, as yet,

been a head-to-head trial of cognitive therapy with any of the other strongly
recommended treatments: cognitive processing therapy (CPT), eye move-
ment desensitization and reprocessing (EMDR) therapy, prolonged expo-
sure (PE), or undifferentiated CBT with a trauma focus.
The participants in these studies included the survivors of motor vehicle
accidents (Ehlers et al., 2003), a terrorist attack and other civil conflicts in
Northern Ireland (Duffy et al., 2007), and a variety of different traumatic
events (Ehlers et al., 2005, 2014). The range of chronicity of PTSD in these
studies varied to include a duration of up to 20 years. In these trials, CT-
PTSD was also found to be highly acceptable to clients, as indicated by very
low dropout rates (3%, on average). It led to very large improvements in
PTSD symptoms (intent-­to-treat pre–post treatment effect sizes of around
2.5 for self-­reported PTSD symptoms), disability, depression, anxiety, and
quality of life, and over 70% of clients (intent-­to-treat) recovered from PTSD.
CT-PTSD was also shown to be superior to a self-help CBT booklet (not
included in the ISTSS evidence review; Ehlers et al., 2003).
Outreach open trials treating consecutive samples of survivors of the
Omagh and London bombings replicated the treatment effects observed in
the trials (Brewin et al., 2010; Gillespie, Duffy, Hackmann, & Clark, 2002).
It is noteworthy that the percentage of clients whose symptoms deteriorated
with treatment was close to zero, and smaller than in clients waiting for
treatment (Ehlers et al., 2014).
Three effectiveness studies implemented CT-PTSD in routine clinical
services and evaluated outcomes in consecutive cases (Ehlers et al., 2013;
Ehlers, Grey, et al., 2020) or a randomized controlled trial (RCT) (Duffy et
al., 2007). The samples treated in these studies included a very wide range
of clients, including those with complicating factors such as serious social
problems, currently living in danger, very severe depression, borderline
personality disorder, or multiple traumatic events and losses. Therapists
included trainees in addition to experienced therapists. Outcomes remained
very good, with large intent-­to-treat pre–post treatment effect sizes of 1.25
and higher for PTSD symptoms. Around 60% of the clients who started
therapy showed clinically significant change/remitted from PTSD. Dropout
rates (around 15%) were somewhat higher than those in the RTCs of CT-
PTSD (3%), but still below the average for RCTs of trauma-­focused CBT of
23% (Bisson, Roberts, Andrew, Cooper, & Lewis, 2013). Hardly any clients
experienced symptom deterioration (1.4% in Ehlers et al., 2013), and it is
unclear whether this was related to treatment. These results, together with
those of Schnurr and colleagues (2007) and Steenkamp, Litz, Hoge, and
Marmar (2015) for PE therapy and CPT, are in line with Stewart and Chamb-
less’s (2009) conclusion that there is some loss of effectiveness in clinically
representative samples compared to RCTs. The reasons remain unclear and
require further investigation. They may include client factors (e.g., chronic-
ity, comorbidity, attitude toward treatment), therapist factors (e.g., level of
Cognitive Therapy 261

training, experience with PTSD), quality and consistency of treatment deliv-

ery (e.g., extent to which the traumas were addressed in treatment), social
factors (e.g., financial problems, stability of living situation, ongoing threat),
and organizational factors (e.g., limits to number or length of sessions in
the service). It is noteworthy that the clients in the CT-PTSD effectiveness
studies did not receive more sessions, on average, than those in the RCTs,
despite the complexity of their mental health and social problems. There
was also evidence that the treatment for clients with multiple traumas and
social problems (who had a somewhat less favorable treatment outcome) was
less trauma-­focused than for other clients in the same cohort (Ehlers et al.,
2013). Thus, the dose of trauma-­focused work they received was less than
ideal.
The efficacy of an intervention does not necessarily show that the
underlying theory of its mechanism is correct. Investigations of the media-
tors of treatment effects are therefore needed. A study using growth curve
modeling in a sample of 268 clients treated with CT-PTSD suggested that,
in line with Ehlers and Clark’s (2000) model, changes in negative apprais-
als drive changes in symptoms during treatment and not vice versa (Kleim
et al., 2013). Wiedemann and colleagues (2020) replicated this result in a
second consecutive cohort of clients treated with CT-PTSD and showed
that the results extend to the other factors proposed in Ehlers and Clark’s
model: disjointedness of memories and maintaining behaviors such as safety
behaviors, rumination, and thought suppression. Charquero-­Ballester and
colleagues (2019) analyzed patterns of brain network activation during a
task that involved trauma-­related and neutral pictures before and after CT-
PTSD. Consistent with Ehlers and Clark’s model, before therapy the brains
of people with PTSD underutilized two subcomponents of the default mode
network that are linked to memory contextualization and to mentalizing
about self and others, compared to brains of traumatized and nontrauma-
tized controls. After successful cognitive therapy, these differences in brain
activity no longer occurred.
Overall, the evidence suggests that CT-PTSD is a safe and efficacious
treatment for adults and children with PTSD following a wide range of trau-
mas. However, the sample sizes were modest, and a need exists for further
RCTs of CT-PTSD in some populations, such as survivors of abuse in early
childhood or military veterans. RCTs comparing CT-PTSD against non-­
trauma-­focused CBT would also be desirable. The treatment techniques
used in CT-PTSD complement each other and are theoretically derived, but
there are no dismantling studies so that it is not known whether all com-
ponents are necessary. Effectiveness studies showed good results, but there
was some loss of overall effects, and further studies of moderators of treat-
ment effects are needed to determine whether subgroups of clients may
require further adaptation of treatment procedures, especially the minority
of about 20% who do not show reliable improvement in symptoms. Further
studies of treatment mechanisms would also be desirable. For example, it
262 Treatments for Adults

would be interesting to compare the theory-­derived specific mechanisms

(reduction of maintaining appraisals, memory characteristics, cognitive
strategies and behaviors) with nonspecific mechanisms such as therapeutic
alliance.

Practical Delivery1
Duration of Treatment
For clients who currently reexperience a small number of traumas, CT-
PTSD is usually delivered in up to 12 weekly sessions of 60–90 minutes,
and up to three optional monthly booster sessions. The mean number of
sessions is approximately 10. Weekly measures of PTSD symptoms, depres-
sion, and appraisals (the Post-­Traumatic Cognitions Inventory [PTCI]; Foa,
Ehlers, Clark, Tolin, & Orsillo, 1999), memory characteristics, rumination,
and safety behaviors are helpful in monitoring the effects of the interven-
tions and spotting remaining problems. For clients with multiple traumas
that need to be addressed in treatment, more sessions are offered (usually
around 20, but more may be required if the client has significant comorbid-
ity or needs help with significant social problems). Note that for sessions
including work on the trauma memory, such as imaginal reliving, updating
memories, or the site visit, the therapist needs to allow sufficient time for the
memory to be processed. Before going home, the client needs adequate time
to refocus on current reality and his or her further plans for the day. These
sessions would usually last around 90 minutes. Variations of the treatment
format are also effective. A 7-day intensive version of the treatment (deliv-
ered over 7 consecutive working days, with 2–4 hours of treatment per day,
plus a few booster sessions; Ehlers et al., 2014; Murray, El-­Leithy, & Billings,
2017) and a self-study assisted brief treatment are similarly effective (Ehlers,
Wild, et al., 2020). Regular case supervision is strongly recommended as it
helps therapists generate different perspectives on the client’s appraisals,
provides support, and ensures adherence to protocol.

Assessment
After traumatic events, people may develop a range of psychological prob-
lems. Having experienced a trauma therefore does not necessarily mean that
a client has PTSD and requires trauma-­focused treatment. A careful diag-
nostic assessment is needed to ascertain that PTSD is one of the client’s main
problems. Risk to self and others must be assessed, and in some cases risky
symptoms and behaviors may need to be an initial priority. Comorbid dis-
orders, their onset and relationship to the trauma should also be assessed.

1A guide for therapists, video illustrations of treatment procedures, and treatment mate-
rials are available free of charge at https://oxcadatresources.com.
Cognitive Therapy 263

Other problems that may interfere with treatment (e.g., court cases, housing
problems, pending surgery, interpersonal issues, debt, unclear outcome of
an asylum application) should also be considered but do not rule out treat-
ment.

How to Do CT‑PTSD
A therapist’s guide to CT-PTSD is available free of charge at https://oxcadat­
resources.com. Here, we describe two unique procedures of CT-PTSD and
some general points.

How to Achieve Emotional Shift through Cognitive Work

Cognitive therapy changes emotions through changes in cognitions, but it
is important to bear in mind that generating an alternative interpretation
(insight) is usually not sufficient to generate a large emotional shift. Cru-
cial steps in therapy are to test the client’s appraisals in behavioral experi-
ments or surveys, which create experiential new evidence against the client’s
threatening interpretations. For example, behavioral experiments for clients
with an overgeneralized sense of danger aim to modify their appraisals (e.g.,
“People can spot that I am an easy target”) by specific assignments (e.g.,
going to a local shop to buy bread) that test their predictions (e.g., “I will be
attacked again”). During the experiment, clients drop any safety behaviors
(e.g., crossing the road when someone approaches) and hypervigilance and
apply the “then versus now” discrimination technique (i.e., looking at other
people to see how different they look from the perpetrator, paying atten-
tion to all the differences between the current situation and the trauma).
The latter is important as intrusive memories may otherwise give clients the
impression that they are under threat. Similarly, they link the new meanings
to the relevant moments during the trauma in memory with the updating
memories procedure, that is, by simultaneously holding the moment and the
new meanings in mind to facilitate an emotional shift.

Focus on Appraisals That Induce a Sense of External or Internal

Current Threat
People with PTSD often have a wide range of problems and of unhelpful
cognitions. This can feel overwhelming for clients and therapists, and it is
important for therapists and clients to agree that they will prioritize the
PTSD work for a limited time and remain trauma-­focused for the majority
of the sessions, that is, to remain focused on the memories and appraisals
that stem from the client’s traumas and their aftermath. Our experience in
supervision is that when therapists feel stuck, it helps to focus again on the
question of which cognitions maintain the sense of internal or external cur-
rent threat.
264 Treatments for Adults

Changing Meanings of Trauma by Updating Trauma Memories

CT-PTSD uses a special procedure to access and shift problematic meanings
(appraisals) of the trauma called the updating trauma memories procedure.
This involves three steps, as listed below.

• Step 1: Accessing and identifying personal meanings of the trauma that lead
to a sense of current threat
| Access hot spots in memory (i.e., the moments during the trauma

that create the greatest distress and sense of “nowness” during

recall). Useful techniques include imaginal reliving, narrative writ-
ing, and questions about the worst moments of the trauma.
| Discuss the content of intrusive memories and determine what

moments of the trauma they represent (often omitted when talking

about the trauma); then include these moments in imaginal reliv-
ing or narrative.
| Explore the personal meanings of these moments.

• Step 2: Identifying updating information

| Identify updating information—­ information that does not fit with
the meanings, either from what happened during the course of the
event, information from reliable sources, or by considering a wider
range of interpretations in cognitive restructuring.
• Step 3: Incorporating personal meanings of hot spots in memory
| Link the new information with the relevant moments in memory;

the client holds the moment in mind while reminding him- or her-
self of updating information (reminders can be verbal, movement,
touch, sounds, smells, tastes, or images).
| Include updates in the narrative of this event.
| Discuss how the client can remind him- or herself of the updates.

STEP 1: ACCESSING AND IDENTIFYING THREATENING PERSONAL MEANINGS

The first step involves accessing the worst moments of the trauma and their
meaning through careful questioning (e.g., “What was the worst thing about
this?”; “What did you think was going to happen?”; “What did this mean to
you at the time?”; “What does this mean to you now?”; “What would it mean
if what you feared most did happen?”). It is important to ask direct questions
about clients’ worst expected outcome, including their fears about dying,
and to elicit the underlying meanings, as this guides what information is
needed to update their trauma memory.
Imaginal reliving and narrative writing each have particular strengths
in accessing the worst moments of the traumas (hot spots; Foa & Rothbaum,
1998) and their meanings, and the relative weight given to each in CT-PTSD
depends on the client’s level of engagement with the trauma memory and the
length of the event. Imaginal reliving (Foa & Rothbaum, 1998) is particularly
Cognitive Therapy 265

powerful in facilitating emotional engagement with the memory and access-

ing details of the memory (including emotions and sensory components).
CT-PTSD only uses a few relivings (usually two to three) to access the hot
spots sufficiently to assess their problematic meanings and move on to the
steps of updating the meaning. Note that hot spots are addressed one at a
time, and straightforward updates such as “I did not die” may be attempted
as soon as the hot spot is identified, which can be as early as Session 1 or 2.
Identifying hot spots may take longer if clients suppress their reactions or
skip over difficult moments because, for example, they are ashamed about
what happened.
Writing a narrative (Resick & Schnicke, 1993) is particularly useful when
the traumatic event lasted for an extended period of time, if clients dissoci-
ate and lose contact with the present situation or have a very strong physical
reaction (e.g., feeling faint, vomiting) when remembering the trauma, or
when aspects of what happened or the order of events is unclear. The narra-
tive is useful for considering the event as a whole and for identifying infor-
mation from different moments that have implications for the problematic
meanings of the trauma.

STEP 2: IDENTIFYING UPDATING INFORMATION

Once a hot spot and its meaning are identified, the next step is to identify
information that does not fit with the problematic meanings (updating infor-
mation). Some of the updating information may concern what happened in
the trauma or afterward, and can be something that the client is already aware
of, but has not yet been linked to the meaning of this particular moment in
his or her memory, or something the client only remembers during imaginal
reliving or narrative writing. Examples include knowledge that the outcome
of the traumatic event was better than expected (e.g., the client did not die,
is not paralyzed); information that explained the client’s or other people’s
behavior (e.g., the client complied with the perpetrator’s instructions because
he had threatened to kill him; other people did not help because they were in
shock); the realization that an impression or perception during the trauma
was not true (e.g., the perpetrator had a toy gun rather than a real gun).
Information and explanations from reliable sources or experts (e.g., cars are
built in a way that makes explosions after accidents very unlikely; certain
distressing procedures in the hospital were done to save the client’s life) can
also be very valuable in identifying updating information.
For other appraisals, guided discovery to generate an alternative per-
spective is necessary—­for example, for appraisals such as “I am a bad per-
son”; “It was my fault”; “My actions were disgraceful”; or “I attract disas-
ter”—including cognitive therapy techniques such as Socratic questioning,
systematic discussion of evidence for and against the appraisals, behavioral
experiments, discussion of hindsight bias, pie charts, or surveys. Imagery
techniques can also be helpful in widening the client’s awareness of other
266 Treatments for Adults

factors that contributed to the event or in considering the value of alterna-

tive actions. For example, assault survivors who blame themselves for not
fighting back during the trauma may visualize what would have happened
if they had. This usually leads them to realize that had they fought back,
this would have escalated the violence further, and the assailant might have
injured them more seriously.

STEP 3: ACTIVE INCORPORATION OF THE UPDATING INFORMATION

INTO THE HOT SPOTS

Once updating information that the client finds compelling has been identi-
fied, it is actively incorporated into the relevant hot spot. This can be done
as soon as the updating information has been identified for that particular
hot spot, for example, in the same session that the first reliving was done.
Clients are asked to bring this hot spot to mind (either through imaginal
reliving or reading the corresponding part of the narrative) and to then
remind themselves (prompted by the therapist) of the updating information
either (1) verbally (e.g., “I know now that . . . ”); (2) by imagery (e.g., visual-
izing how one’s wounds have healed, visualizing the perpetrator in prison,
looking at a recent photo of the family or of oneself, visualizing the person
who died in the trauma in a peaceful place where he or she is not suffering
any longer); (3) by performing movements or actions that are incompatible
with the original meaning of this moment (e.g., moving about or jumping
up and down for hot spots that involved predictions about dying or being
paralyzed); or (4) through incompatible sensations (e.g., touching a healed
arm). To summarize the updating process, a written narrative is created that
includes the new meanings for each hot spot and highlights them in a differ-
ent font or color (e.g., “I know now that it was not my fault”).

Identification and Discrimination of Triggers

of Reexperiencing Symptoms
Clients with PTSD often report that intrusive memories and other reexperi-
encing symptoms occur “out of the blue” in a wide range of situations. Care-
ful detective work done in collaboration with the therapist usually identifies
sensory triggers that clients have not been aware of (e.g., particular colors,
sounds, smells, tastes, touch, body posture, or movement). To identify these
subtle triggers, client and therapist carefully analyze where and when re-­
experiencing symptoms occur. Systematic observation in the session (by the
client and the therapist) and through homework is usually necessary to iden-
tify all triggers. Once a trigger has been identified, the next aim is to break
the link between the trigger and the trauma memory.
This involves several steps. First, the client learns to distinguish between
“then” and “now,” that is, to focus on how the present triggers and their
Cognitive Therapy 267

context (now) are different from the trauma (then). This leads him or her to
realize that there are more differences than similarities and that he or she is
responding to a memory, not to current reality.
Second, intrusions are intentionally triggered in therapy so that the cli-
ent can learn to apply the then-versus-now discrimination. For example, traf-
fic accident survivors may listen to sounds that remind them of the crash,
such as brakes screeching, collisions, glass breaking, or sirens while focusing
on all the differences between these sounds and their safe context and the
trauma. Other examples include the following. People who were attacked
with a knife may look at a range of metal objects, and those who were shot
may listen to the sounds of gunfire generated on a computer. Survivors of
bombings or fires may look at smoke produced by a smoke machine. People
who saw a lot of blood during the trauma may look at red fluids. The then-
versus-now discrimination can be facilitated by carrying out actions that
were not possible during the trauma (e.g., movements that were not possible
during the trauma, touching objects or looking at photos that remind them
of their present life).
Third, clients apply these strategies in their natural environment.
When reexperiencing symptoms occur, they remind themselves that they
are responding to a memory and focus their attention on how the present
situation is different from the trauma, and may carry out actions that were
not possible during the trauma to remind themselves that the trauma is not
happening again.

Tailored Intervention
As the CT-PTSD case formulation is tailored to each individual, it can be
applied to a wide variety of presentations, traumas, age groups (Smith et
al., 2007), and cultural backgrounds and can incorporate comorbid condi-
tions, the effects of multiple traumas, or the multiple challenges faced by
refugees (Grey & Young, 2008; Raval & Tribe, 2014). For example, comorbid
depression may be related to some of the client’s appraisals of the trauma
and other life experiences (e.g., “I am worthless”) and cognitive strategies
(e.g., rumination). Comorbid panic disorder may have developed from
interpretations of the reexperiencing symptoms (e.g., reexperiencing diffi-
culty breathing, leading to the thought “I will suffocate”). And comorbid
obsessive–­compulsive disorder (OCD) may be linked to appraisals such as
“I am contaminated” and linked behaviors such as excessive washing. Cul-
tural beliefs may influence an individual’s personal meanings of trauma and
his or her attempts to come to terms with trauma memories in helpful and
unhelpful ways. Treatment is tailored to the individual’s beliefs, including
cultural beliefs.
CT-PTSD allows for flexibility in the order in which the core treatment
procedures are delivered. The memory-­updating procedure often has a fast
268 Treatments for Adults

and profound effect on symptoms and is generally started early on. For
patients with severe dissociative symptoms, training in trigger discrimina-
tion is conducted first, and narrative writing is preferred over imaginal reliv-
ing. In addition, for certain cognitive patterns, the memory work is prepared
through discussion of the client’s appraisals and cognitive processing at the
time of the trauma. For example, when a client profoundly believes him- or
herself to be at fault for a trauma, and the resultant guilt and/or shame pre-
vents him or her from being able to describe it fully to the therapist, therapy
would start with addressing such appraisals. If a client experienced mental
defeat (the perceived loss of all autonomy; Ehlers, Maercker, & Boos, 2000)
during an interpersonal trauma, therapy would start with discussing the
traumatic situation from a wider perspective to raise the client’s awareness
that the perpetrators intended to control and manipulate his or her feel-
ings and thoughts at the time, but that they no longer are exerting control
now. Clients who are preoccupied with the injustice of the trauma may first
express their anger in an (unsent) letter to the perpetrator.

When Treatment Does Not Work

A minority of clients do not achieve significant clinical benefit from a course
of CT-PTSD, and the question then arises how best to manage the further
care of these clients. There is no empirical evidence as of yet on how best
to handle this circumstance, but clinical experience suggests a few possi-
bilities. First, it may emerge in the course of therapy that PTSD is currently
not the respective client’s main problem; comorbid conditions (e.g., depres-
sion, OCD, borderline personality disorder, substance use disorder, physi-
cal problems), social problems (e.g., debts, no stable housing, illness in the
family), legal problems (e.g., custody issues, asylum), or a new negative life
event (e.g., death of a significant other) may have become their principal
problem, making them unable to sufficiently engage in a trauma-­focused
treatment at this time. These clients may benefit from treatment for the
comorbid conditions first, and support and problem solving in managing
their social issues or new life event. Non-­trauma-­focused CBT such as stress
management may be helpful in managing their PTSD symptoms during this
time. Another course of CT-PTSD may then be attempted when such a client
is ready to work on his or her trauma memories. Second, some clients may
not fully engage with treatment for practical reasons (e.g., unable to attend
sessions regularly, little time or privacy to work on their homework assign-
ments) or concerns about the treatment (e.g., doubts about its rationale or
anticipated/threatened negative reactions from others). These clients may
find it easier to switch to an intensive or semi-­intensive treatment format.
Third, some clients whose traumas happened many years ago and were life-­
changing, who are socially very isolated, who have many traumas to work
on or long-­standing negative beliefs about themselves and other people, a
Cognitive Therapy 269

longer course of treatment may be indicated. Fourth, some clients may pre-
fer to try a course of medication for PTSD or an alternative treatment such
as non-­trauma-­focused CBT.

Future Developments

Not all clients can attend weekly treatment sessions with a therapist. Novel
forms of treatment delivery are of interest to increase client choice and to
use the therapist’s time efficiently so that more patients can benefit from
treatment. Several variations of treatment delivery have been shown to be
efficacious for CT-PTSD. Intensive delivery of treatment over 5–7 working
days, or settings such as residential therapy units, may be preferable for some
clients (Ehlers et al., 2014). Self-study modules that cover some of the content
of CT-PTSD save about 50% of the therapist’s time without loss of efficacy
(Ehlers, Wild, et al., 2020). They may also be useful in therapist training.
Therapist-­assisted Internet-­delivered CT-PTSD has also shown promise in a
pilot study (Wild et al., 2016) and is currently being investigated in an RCT.
Support is delivered through online messages and weekly phone calls in
20–25% of the time needed in face-to-face therapy.
The best ways to deliver training for CT-PTSD remain to be investigated.
Observations of large-scale efforts to disseminate trauma-­focused CBT, such
as the English National Health Service Improving Access to Psychological
Therapies (IAPT) program and the Veterans Administration health care sys-
tem in the United States (Clark, 2018; Foa, Gillihan, & Bryant, 2013), have
shown that alongside workshops and a manual, supervision of training cases
and use of weekly measures of symptoms to monitor the effect of interven-
tions are important in training therapists to a sufficient standard. Online
training materials that are accessible during training and beyond may help
increase therapists’ competency and confidence in delivering treatment.

Summary

Overall, the evidence suggests that CT-PTSD is a safe and efficacious treat-
ment for adults and children with PTSD with high acceptability to clients,
both in RCTs and routine clinical settings. Studies have included clients with
a wide range of traumas, chronicity, and comorbidity. Nevertheless, there
is a need for further RCTs of CT-PTSD in populations such as survivors of
early childhood abuse or military veterans. New forms of treatment delivery
have shown promise and may help increase client choice and access to treat-
ment. There are gaps in knowledge, though, that still need to be addressed
in further studies. This includes further studies of moderators and media-
tors of treatment effects, and of the best way to train therapists in CT-PTSD.
270 Treatments for Adults

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C H A P TE R 16

Pharmacological and Other

Biological Treatments
Jonathan I. Bisson, Matthew D. Hoskins, and Dan J. Stein

Tbination
he majority of people with posttraumatic stress disorder (PTSD) who pres-
ent for treatment are prescribed medication, either on its own or in com-
with psychological treatment. Given the proven efficacy of several
pharmacological treatments, this represents a major opportunity to improve
the health and well-being of people with PTSD. Unfortunately, the full
potential of pharmacological treatment is not currently realized, not least
as a result of prescribing practice not being based on the evidence currently
available. This chapter aims to help clinicians interpret the current evidence
regarding the prescription of medication for PTSD; provide advice on what,
when, and how to prescribe; and discuss key considerations when prescrib-
ing medication for PTSD. It also considers other biological treatments of
PTSD. Although we will include some discussion of pharmacotherapy aug-
mentation, the use of medication for PTSD prophylaxis, agents specifically
used as adjuncts to psychotherapy, and pharmacotherapy in children and
adolescents are beyond the scope of this chapter.

Theoretical Context

Given our knowledge of the neurobiology of PTSD, there is good reason

to believe that pharmacological treatment approaches should be beneficial.
Important advances in understanding the neurocircuitry, neurogenetics,
and neurochemistry of PTSD have been made. It is currently hypothesized
that a number of different systems are involved in the development and
maintenance of PTSD, with various neurotransmitters, neuropeptides, and

272
Pharmacological and Other Biological Treatments 273

glucocorticoids being implicated in its neurobiology, including catechol-

amines, opioids, gamma aminobutyric acid (GABA), glutamate, serotonin,
oxytocin, and cortisol.
Considerable evidence exists, for example, from animal research on
fear conditioning, and from clinical research on PTSD to suggest that over-
activity of the noradrenergic system is a fundamental element of this disor-
der and that attenuation should be beneficial (Southwick et al., 1999). There
are various ways to do this, either directly through drugs that work through
their effects on adrenergic receptors (e.g., propranolol and prazosin) or indi-
rectly (e.g., hydrocortisone to reduce noradrenaline release). This neurobio-
logical work has given impetus to a range of clinical trials in PTSD.
Promising data from both preclinical and clinical work have the poten-
tial to inform prescribing for PTSD. There is also a view that a better under-
standing of the range of neurobiological alterations in PTSD will help lead
to personalized interventions for this disorder. At the same time, our under-
standing of the neurobiology of PTSD remains partial, and the limited effect
of many drugs in clinical trials highlights the need for more research that
may lead to the development of more effective pharmacological treatments
for PTSD.

Description of Techniques

• Selective serotonin reuptake inhibitors (SSRIs). The most common

approach to the pharmacological treatment of PTSD is the prescription of
an SSRI. This class of drugs, which includes citalopram, fluoxetine, parox-
etine, and sertraline, is widely prescribed for depression and anxiety.
• Serotonin and noradrenaline reuptake inhibitors (SNRIs). Duloxetine and
venlafaxine are the most widely used SNRIs. At lower doses, their effect is
similar to that of SSRIs, but at higher doses, some of these agents also inhibit
the reuptake of another monoamine, noradrenaline, leading to greater avail-
ability of this chemical within synapses.
• Monoamine reuptake inhibitors (MARIs). This group of drugs, com-
monly known as tricyclic antidepressants, includes amitriptyline, dothiepin,
and imipramine. In addition to serotonin and noradrenaline, these agents
antagonize histamine H1 receptors, a property sometimes used to help
insomnia.
• Monoamine oxidase inhibitors (MAOIs). Phenelzine and tranylcypro-
mine are probably the best known MAOIs and work by inhibiting the actions
of enzymes that break down monoamines, thereby also increasing the
amounts of synaptic monoamine. Their association with a hypertensive cri-
sis after eating certain foods has discouraged practitioners from prescribing
them, although with care they can be relatively safe and well-­tolerated drugs.
274 Treatments for Adults

• Other antidepressants. Other antidepressants are widely used to treat

PTSD. Mirtazapine exerts its main effects on serotonin, noradrenaline,
and histamine through a different mechanism than other antidepressants.
Sedation is a common side effect that is sometimes used to treat insomnia
in PTSD sufferers. Trazadone primarily affects the serotonin system, with
a weaker effect on histamine. Its sedative side effect is also used to treat
insomnia so the drug is often prescribed in combination with an SSRI or
SNRI to assist sleep rather than as an antidepressant per se.
• Antipsychotics. The most commonly used antipsychotics for PTSD
are the newer-­generation “atypical antipsychotics,” for example, olanzap-
ine, quetiapine, and risperidone. Like older antipsychotics, they are anti-­
dopaminergic but they also affect the serotonergic system. The result is gen-
erally a tranquilizing drug without as marked motoric side effects as the
“typical antipsychotics,” although they do have a number of other adverse
effects that can be problematic, including weight gain, oversedation, and the
development of a metabolic syndrome that is associated with cardiovascular
disease and diabetes.
• Benzodiazepines. Despite widespread serious concerns about the risk
of dependency and regulatory warnings not to prescribe benzodiazepines
for more than a few weeks, these medications are still frequently prescribed
to PTSD sufferers. Commonly used drugs in this class include those pre-
scribed for anxiety reduction, for example, diazepam, and those prescribed
for sedation, for example, temazepam.
• Anticonvulsants. Most anticonvulsants impact the GABA system and
calcium and/or sodium channels, reducing glutamate release and prevent-
ing the excitability that results in a convulsion. These drugs include carba-
mazepine, lamotrigine, and valproate and have been used increasingly for
mood stabilization and as adjunctive treatments across a range of mental
disorders.
• Other drugs. Other drugs have been used to treat PTSD, including
agents that act on the noradrenergic system (e.g., prazosin and proprano-
lol), or other components of the hypothalamic–­pituitary–­adrenal axis (e.g.,
hydrocortisone).

Summary and Appraisal of the Evidence

Monotherapy
The evidence summaries prepared for the guidelines issued by the Interna-
tional Society for Traumatic Stress Studies (ISTSS) concerned randomized
controlled trials (RCTs) of pharmacological treatments used as monother-
apy for PTSD. Forty-nine includable RCTs were found that considered 16
drugs. Thirty-­nine (80%) of the included RCTs had usable data that were
Pharmacological and Other Biological Treatments 275

included in the meta-­analyses. Nineteen (49%) were of the SSRIs fluoxetine,

paroxetine, and sertraline, with venlafaxine being the only other drug with
more than 500 individuals included in a single meta-­analysis.
Fluoxetine, paroxetine, sertraline, and venlafaxine all satisfied the
requirement for a Low Effect recommendation. This signifies robust evi-
dence of reasonably high quality that these treatments will result in small
but clinically significant benefits for people with PTSD who take them. The
only other drug with strong enough evidence to recommend was quetiapine,
which received an Intervention with Emerging Evidence recommendation for
the treatment of PTSD in adults.
There was insufficient evidence for the other drugs included to be rec-
ommended, but it is interesting to note that four of them (amitriptyline,
mirtazapine, a neurokinin-1 antagonist, and phenelzine) were significantly
superior to placebo in trials with insufficient participants (<20 per arm) to
meet the threshold for recommendation. These drugs are good candidates
for further research and may prove to be effective treatments for PTSD.
Most of the RCTs included were of general populations of outpatients
with PTSD who had been traumatized by a variety of events, and the results
therefore should be generalizable to various populations. That said, it has
been proposed that there are differential drug effects across PTSD popu-
lations (e.g., ICD-11 [World Health Organization, 2018] includes “complex
PTSD” as a new diagnosis, which deserves additional pharmacotherapy
research).
It is very difficult to compare the results of pharmacological treatment
trials employing placebo controls and double blinding with psychological
treatment trials using wait-list or usual-care controls, with neither the par-
ticipant nor the treating clinician being blinded to treatment. In common
with other guideline development groups, the ISTSS Guidelines Committee
determined a priori rules to allow comparison of different types of treat-
ment, making the threshold required for a Strong recommendation for a
drug tested through placebo-­controlled RCTs 50% less than that for psycho-
logical treatments tested through wait-list or usual-care RCTs. Whether the
50% lower threshold accurately reflects the true level is open for debate, but
using this meant that the best-­evidenced drug treatments for PTSD were
recommended at a lower level of strength than the psychological treatments
with the best evidence of treatment for PTSD.
There is a small evidence base that directly compares pharmacotherapy,
psychotherapy, or combined treatment. An early meta-­analysis of four trials
(Hetrick, Purcell, Garner, & Parslow, 2010) found insufficient evidence to
determine the relative efficacy of combined treatment, and subsequent tri-
als have been inconsistent (Popiel, Zawadzki, Praglowska, & Teichman, 2015;
Schneier et al., 2012; Simon et al., 2008). Nevertheless, in clinical practice,
combined treatment is often employed (Marshall & Cloitre, 2000), and there
is ongoing research interest in “medication-­assisted psychotherapy” (Amo-
roso & Workman, 2016). In many regions, prescribing a drug with evidence
276 Treatments for Adults

of effect is often the only potentially effective treatment available, given wait-
ing lists for evidence-­based psychological treatments, with pharmacotherapy
becoming the default treatment and psychotherapy combined at a later date.
The ISTSS guideline recommendations for drugs used as monotherapy
for PTSD are shown in Table 16.1.

Augmentation
Although the ISTSS guideline scoping questions did not include queries
regarding augmentation of pharmacological treatment with additional
pharmacological treatment, a parallel review using the same searches was
undertaken concerning this question and will be referred to in this chapter.
Sixteen studies were included covering three drugs: prazosin (nine studies,
381 participants), risperidone (five studies, 385 participants), and topira-
mate (two studies, 97 participants). There was sufficient evidence to issue
a Standard recommendation for prazosin and risperidone but insufficient
evidence to recommend topiramate, which was not statistically superior to
placebo.

Quality of the Evidence

The quality of the pharmacological RCTs, assessed by the Cochrane risk of
bias tool (Higgins & Green, 2011) and modified GRADE criteria (see www.
gradeworkinggroup.org), included in the meta-­ analyses was moderate but,
overall, comparable with the highest-­quality psychological RCTs included in
the meta-­analyses that informed the guidelines. There were some issues that
indicated risk of bias in the results, especially with respect to the selective
reporting of results. Some studies did have more fundamental methodologi-
cal flaws or lack of clarity around randomization concealment and blind-
ing of posttreatment assessors. The studies included in the meta-­analyses
displayed quite significant statistical and clinical heterogeneity, both of
which impact interpretation of the results to a degree. The majority of par-
ticipants included in the RCTs had had their PTSD for a number of years

TABLE 16.1. ISTSS Guideline Recommendations for Pharmacological Monotherapy

Interventions with Low Effect—Fluoxetine, paroxetine, sertraline, and venlafaxine
are recommended as low effect treatments for adults with PTSD.
Intervention with Emerging Evidence—Quetiapine has emerging evidence of
efficacy for the treatment of adults with PTSD.
Insufficient Evidence to Recommend—There is insufficient evidence to
recommend amitriptyline, brofaromine, divalproex, ganaxolone, imipramine,
ketamine, lamotrigine, mirtazapine, neurokinin-1 antagonist, olanzapine,
phenelzine, tiagabine, or topiramate for the treatment of adults with PTSD.
Pharmacological and Other Biological Treatments 277

and exhibited moderate to severe symptoms of PTSD. Most RCTs had broad
inclusion criteria for traumatic events, meaning that participants had been
exposed to various traumatic events. PTSD had to be the primary condition,
but some comorbidity was common. Most studies included depression but
excluded potential participants who were suicidal, had psychosis or other
major comorbidities such as substance dependence. The vast majority of
the studies were undertaken in higher-­income countries. All of these factors
raise questions around the generalizability of the findings to people with
PTSD who would not have been included in the studies and to those living
in different settings than where the research studies were conducted.

Dosing
Another important factor to consider, especially with respect to implementa-
tion of the evidence, is the doses of medication that were used in the studies.
Some studies (e.g., Marshall, Beebe, Oldham, & Zaninelli, 2001; Martenyi,
Brown, & Caldwell, 2007) used fixed doses, but most studies followed a pre-
scribing algorithm whereby drug dosage was increased every few weeks if
individuals did not recover. The mean doses of the recommended drugs
used are shown in Table 16.2; they are well above the standard starting
doses. It is clear that a number of individuals needed the maximum level
of medication allowed and tolerated during the trial to achieve maximum
benefit, indicating that they did not improve sufficiently with lower doses.
The caveat here is that if a longer duration of time had elapsed before
increasing a dose in the RCTs, then it is possible more participants would
have improved on lower doses. Indeed, it has been argued that improve-
ments can take longer to occur following an increase in medication for PTSD
than for depression (National Collaborating Centre for Mental Health,
2005), although the evidence for this claim is not strong. The current evi-
dence certainly suggests that it is inappropriate to keep people with PTSD
on lower doses of the recommended drugs if they have not or only partially
responded, are tolerating the medication prescribed, and treatment remains
indicated.

TABLE 16.2. Mean Trial Doses

of Recommended Drugs
Drug Mean dose

Fluoxetine 41.4 mg
Paroxetine 35.1 mg
Sertraline 136.7 mg
Venlafaxine 223.1 mg
Quetiapine 258.0 mg
278 Treatments for Adults

Adverse Effects
Due to regulatory requirements, the reporting of adverse effects in phar-
macological treatment trials tends to be much better than for psychological
treatment trials. Those reported in PTSD treatment trials are very similar
to those reported in trials with the same drugs for depression, anxiety, and
other disorders. Common adverse effects for paroxetine, fluoxetine, sertra-
line, and venlafaxine include nausea and sexual dysfunction. Quetiapine
can cause sedation and weight gain, and has been associated with cardiac
effects, meaning that an electrocardiogram is required before initiating
treatment with it. Overall, the recommended drugs appeared to be reason-
ably well tolerated in the included RCTs and there was no evidence that they
should not be considered for use because of adverse effects.

Practical Delivery of the Recommendations

As with all treatments for PTSD, it is vital that pharmacological treatment
only be prescribed after an accurate assessment of a client’s needs that takes
into account her or his individual circumstances. Key issues to consider
before prescribing medication (or in weighing whether to prescribe medi-
cation, psychotherapy, or combined treatment) include primary diagnosis;
comorbidity; alternative treatment options; attitude toward medication;
previous response to medication; family history of response to medication;
expectations of medication; awareness of potential adverse effects; other
prescribed drugs and potential interactions with medication for PTSD and
other substance use and potential interactions with medication for PTSD.
Medication for PTSD should only be prescribed when a clinician believes the
likely benefits outweigh the risks and when the individual is equipped with
the knowledge necessary to make a fully informed decision.
Prescribing medication is often suboptimal, and this has led to attempts
to formalize prescribing through the development of prescribing algorithms.
This is common practice in many disorders and is widely used for mental
health disorders (e.g., Taylor, Barnes, & Young, 2018). Research in depres-
sion has shown that prescribing according to an algorithm resulted in sig-
nificantly better outcomes than prescribing based purely on clinician choice
(Guo et al., 2015). It seems likely that this finding would apply to PTSD,
leading the Cardiff University Traumatic Stress Research Group to develop a
prescribing algorithm based on the ISTSS treatment recommendations (Bis-
son, Baker, Dekker, & Hoskins, 2020). This is being introduced nationally
through the All Wales Traumatic Stress Quality Improvement Initiative and
will be referred to in this chapter to highlight an example of how the ISTSS
pharmacological treatment recommendations are being implemented into
practice.
There are a number of principles that underpin the Cardiff algorithm:
Pharmacological and Other Biological Treatments 279

1. As a general rule, only one medication should be introduced or

changed at once.
2. Patients should be reviewed at least every 4 weeks to consider their
progress and tolerance of medication, and to determine if a change
to medication is required.
3. Although tied to the evidence base, some flexibility based on other
factors is allowed, in line with evidence-­ based practice (Sackett,
Rosenberg, Muir Gray, Haynes, & Richardson, 1996).
4. Regular consideration should be given to the accuracy of the diag-
nosis and the presence of other factors that need addressing to facili-
tate the effectiveness of medication (e.g., compliance, social factors,
and alcohol misuse).

These principles are pragmatic and reflect good clinical practice, but
it is acknowledged that other factors, for example, configuration of local
services, and mental and physical comorbidities, may necessitate changes to
the algorithm.

Algorithm‑Based Pharmacological Treatment for PTSD

Step 1
If an individual with PTSD and her or his treating clinician agree that treat-
ment with medication is indicated and desired, the most logical approach,
based on the current evidence base, would be to prescribe one of the three
recommended SSRIs (fluoxetine, paroxetine, or sertraline). Unless there
are any contraindications, the drugs should be prescribed using the doses
suggested in Table 16.3. If, after 4 weeks, the patient continues to experi-
ence significant PTSD symptoms and is tolerating the medication, and it is
agreed that pharmacological treatment should be continued, the dose ought
to be increased by the amount shown in Table 16.3. This procedure would be
repeated, resulting in an individual with PTSD who is tolerating medication
but continues to exhibit symptoms, reaching the maximum dose of fluox-
etine and paroxetine at Week 8 and sertraline at Week 12. A further 4 weeks

TABLE 16.3. Recommended Pharmacological Treatment Doses

Starting Dose Dosing Increment Maximum Dose
Drug (daily) (monthly) (daily)

Fluoxetine 20 mg 20 mg 60 mg
Paroxetine 20 mg 20 mg 60 mg
Sertraline 50 mg 50 mg 200 mg
Venlafaxine 75 mg 75 mg 300 mg
280 Treatments for Adults

should be allowed to determine the response to the maximum dose before

making any further changes.

Step 2
If an individual has not responded to the maximum tolerated dose of one
of the SSRIs, an alternative medication should be considered. Before doing
this, it is important to check that there have been no changes to the clinical
presentation and that both the patient and the clinician consider ongoing
pharmacological treatment appropriate. The next step involves reducing the
existing drug and replacing/cross-­tapering it with an alternative. It would be
reasonable to try a different SSRI, particularly if an individual has not toler-
ated one SSRI and may improve with another. If an individual has not shown
a significant response to a particular SSRI, it is theoretically unlikely that he
or she will do significantly better with an alternative SSRI, and the introduc-
tion of venlafaxine is therefore a logical next step. To introduce venlafaxine,
the SSRI should be reduced by the incremental dose on a weekly basis and,
at the point of stopping, venlafaxine introduced at 37.5 mg twice a day or 75
mg in the morning if the long-­acting preparation has been prescribed. The
individual should be reviewed monthly with the dose of venlafaxine titrated
up by 75 mg at a time to a maximum of 300 mg daily, if needed.

Step 3
In the absence of an adequate response to venlafaxine and subject to it being
tolerated, the next step would be to augment it with either prazosin (with
particular attention being paid to postural hypotension1) or risperidone.
(If an individual does not tolerate venlafaxine or responds less well to it
than to an SSRI, it is recommended that the SSRI be reinstated in place of
venlafaxine and augmented.) Given the side-­effect profile of risperidone,
the Intervention with Emerging Evidence recommendation of quetiapine, and
its more favorable side-­effect profile, this drug may be used in preference
to risperidone. It is, however, acknowledged that the current evidence for
quetiapine comes from an RCT in which it was used as a monotherapy and
not for augmentation. Quetiapine is initiated at 25 mg a day at night. After
1 week, if tolerated, it is increased to 25 mg twice a day. The dose can be
increased by 50 mg a day increments, as indicated, at monthly appointments
with a clinician. A maximum of 400 mg a day, based on clinical response and

1 Asthere is a risk of severe first-dose hypotension, the first and second doses should be
taken while sitting on a bed just before lying down. It is important to keep well hydrated
while taking prazosin and to get up slowly—­initially sitting up on the bed and then slowly
standing up. For the first two nights, it is important for men to sit on the toilet to urinate
rather than stand up.
Pharmacological and Other Biological Treatments 281

tolerability, is recommended in the algorithm, although up to 800 mg daily

was used in the trial (Villarreal et al., 2016).

Additional Steps
If people with PTSD do not respond to fluoxetine, paroxetine, sertraline, or
venlafaxine on their own or in combination with prazosin, risperidone, or
quetiapine, prescribed as described in Steps 1, 2, and 3, they have reached
the end of the current evidence-­based pharmacological treatment algorithm
for PTSD. Unfortunately, this is not an uncommon occurrence, especially
in individuals with more complex or severe presentations of PTSD. It is also
not uncommon for people with PTSD to be unable to tolerate the maximum
dose of one or more drugs. In both these scenarios, alternative steps can
be considered but become more evidence-­informed than evidence-­based.
Before embarking on such an approach, it is clearly vital that the patient be
fully aware of the situation and able to make a fully informed decision about
continuing with pharmacological treatment.
As stated, other pharmacological treatments have been shown to ben-
efit people with PTSD in RCTs but did not meet the requirements to be rec-
ommended in the latest ISTSS treatment guidelines. Several of these have
been recommended in previous guidelines for the treatment of PTSD, for
instance, the National Institute of Health and Care Excellence in the United
Kingdom recommended amitriptyline, mirtazapine, and phenelzine based
on the same RCT evidence available when the current ISTSS guidelines were
developed. A network meta-­analysis of drug trials in PTSD also highlighted
the potential value of phenelzine (Cipriani et al., 2018). It is therefore rea-
sonable to consider these drugs as alternatives to those recommended by
ISTSS if the latter do not work or cannot be tolerated.
Mirtazapine has the advantage of being able to be prescribed in com-
bination with SSRIs and venlafaxine; indeed, some evidence of benefit
has been reported for such combinations in depression (Blier et al., 2010),
although a large recent pragmatic RCT did not show benefit from the addi-
tion of mirtazapine in primary care (Kessler et al., 2018). In general, mir-
tazapine is started at 30 mg at night, although it can be prescribed at 15 mg
that, paradoxically, is more sedative than higher doses, and this dose tends
to be favored if the drug is being prescribed primarily to help with sleep.
Amitriptyline and, particularly, phenelzine should not be prescribed in
combination with SSRIs or venlafaxine, and a wash-out period of at least a
week (or 5 weeks for fluoxetine) is required before starting phenelzine. The
prescribing regimen for amitriptyline is to start low (25 mg at night) and
gradually build up to a maximum dose of 300 mg, although this is rarely
required or tolerated and a more common dose is approximately 150 mg.
Phenelzine should be started at 15 mg three times a day. It is important to
consider postural hypotension with phenelzine, which is a not uncommon
side effect, and warn patients about this.
282 Treatments for Adults

The other group of drugs that can be considered as an evidence-­

informed treatment of PTSD are anticonvulsants. There is no strong RCT
evidence for any of these medications; indeed, the RCTs have been neutral
to date for those tested (valproate, topiramate, lamotrigine) but they are
widely used as mood stabilizers, show evidence of effect in other mental
disorders, and have been reported to help some people with PTSD (Berlin,
2007). Another anticonvulsant, carbamazepine, has been shown to help with
episodic dyscontrol (Lewin & Sumners, 1992), a feature of some presenta-
tions of PTSD, and there is non-RCT evidence of benefit in military veterans
with PTSD (Lipper et al., 1987).

Other Factors That Influence Prescribing

There are a number of commonly experienced challenges to prescribing
medication for PTSD that deserve particular attention and are described
next.

Inability to Tolerate Medication Due to Adverse Effects

Although all the commonly prescribed medications are reasonably well toler-
ated overall, adverse effects are, unfortunately, common. As described previ-
ously, it is important for the clinician to discuss possible common adverse
effects with the patient as part of the shared decision-­making process. The
presence of adverse effects should be considered at every review, and a dis-
cussion must ensue if they are detected. Key issues to consider before deter-
mining how to proceed include the severity of the adverse effect, likelihood
of improvement or deterioration, impact on the patient, and balance against
any benefits or potential benefits accruing from the medication.
In some instances, it may be that discussion and some reassurance will
allow a patient to decide to continue with his or her medication and tolerate
an adverse effect as the potential benefits outweigh the potential harms. For
example, nausea is relatively common when individuals start taking SSRIs or
venlafaxine, but it tends to lessen over a few weeks and can also be reduced
by taking the medication with food. It may be that, due to adverse effects, a
patient can tolerate a lower dose but not a higher dose of a particular drug. It
is then important to discuss the pros and cons of continuing with that drug.
For example, paroxetine is more likely to cause agitation than sertraline,
and the inability to tolerate paroxetine beyond 20 mg would be a good rea-
son to consider switching to sertraline to determine if it is better tolerated at
higher doses before trying a different class of drug.

Insomnia
Many people with PTSD find insomnia to be a particular problem and ask
specifically for medication to help them sleep. Individuals who respond well
Pharmacological and Other Biological Treatments 283

to SSRIs and venlafaxine will generally report improved sleep, but these
drugs are not sedatives and can be associated with increased wakefulness
(hence the general recommendation to take them in the morning). It is
important that patients are aware of this effect. Most will be willing to wait
for these drugs to work, but this usually takes several weeks and it is some-
times appropriate to consider prescribing a sedative medication in addition.
When indicated, it is recommended that a sedative antidepressant be
considered first line, for example, 15 mg of mirtazapine at night (which has
the added benefit of RCT evidence to support its use for PTSD) or 50–100
mg of trazadone at night. Both of these drugs can be safely prescribed with
SSRIs and venlafaxine and are not associated with the addictive potential of
drugs such as benzodiazepines or the Z drugs. An alternative, especially for
individuals with significant agitation (see below) is 25 mg of quetiapine at
night. It is important to be aware that mirtazapine, trazadone, and quetia­
pine can cause drowsiness the following day and to warn patients about this.

Agitation
Agitation is common when individuals present with PTSD and, unfortu-
nately, an unwanted early adverse effect of the SSRIs and venlafaxine is
agitation/increased anxiety and even suicidality. For the majority of people
with PTSD, adjunctive medication for agitation is not necessary, but for some
individuals it is likely to be needed and, in addition to reducing agitation,
may also enable a person to tolerate and continue medication likely to help
her or his PTSD. Given its profile and evidence for use for PTSD, quetiapine
is recommended as an adjunct or even on its own if a patient is very agitated
or does not want to take SSRIs or venlafaxine. Some doctors recommend
short courses of benzodiazepine for such agitation, but we do not recom-
mend this, given the lack of evidence for benzodiazepine use for PTSD and
also the risk of dependency.

Future Developments

There is clearly a need to improve the evidence available for pharmacologi-

cal approaches to PTSD. There are some emerging candidates, but more
research is needed to identify novel pharmacological treatments that may
help. This is likely to result from greater neurobiological research; recent
larger-­scale PTSD genetics research has identified specific genes associ-
ated with PTSD (Duncan et al., 2017) that may herald a new, more focused
approach to the development of effective pharmacological treatments. There
is also a need for more clinical research with existing drugs; for example, we
need to develop a greater understanding of the efficacy of drugs for differ-
ent presentations of PTSD and combination pharmacological and psycho-
logical treatment.
284 Treatments for Adults

An urgent need also exists to ensure that our current knowledge with
regard to the pharmacological treatment of PTSD is disseminated and imple-
mented in practice across the world, and that we move to pragmatic trials and
the study of treatment algorithms in everyday clinical practice. We must strive
to ensure that people with PTSD are fully informed about evidence-­based
pharmacological treatment so they can make an informed decision on whether
to try a particular approach or not. If such a scenario was the norm, many more
people with PTSD would be provided with evidence-­based pharmacological
treatment and experience improved health and well-being as a result.

Other Biological Treatments

Currently, other biological treatments have less evidence to support their
use than pharmacological treatments but, in recent years, some promising
approaches have emerged. Transcranial magnetic stimulation, neurofeed-
back, and Saikokeishikankyoto (an herbal preparation) were all recom-
mended by the ISTSS guidelines as having emerging evidence of effect as
interventions for the treatment of PTSD. The relatively small number of
RCTs and participants involved, and other methodological issues, mean that
further work is required before they can be recommended for routine use,
but all are good candidates for more research.
Transcranial magnetic stimulation (TMS) uses magnetic fields to stimu-
late nerve cells in targeted areas of the brain. It is usually administered in a
repetitive manner and is noninvasive. TMS is licensed for the treatment of
depression, and there has been a significant rise in interest in its potential as
a treatment for PTSD in recent years. The four RCTs that have been under-
taken to date show signs of early promise in individuals who have not been
helped by other approaches. TMS needs to be delivered in a specialist facil-
ity and, although it appears to be well tolerated, there is a risk of reduced
seizure threshold.
Neurofeedback involves real-time displays of brain activity through
EEG or fMRI that train individuals to self-­regulate their brain activity and,
for example, feel more relaxed. The two included RCTs showed evidence of
efficacy, and the treatment was well tolerated. Neurofeedback also needs to
take place in a specialist facility.
Saikokeishikankyoto is a traditional Japanese herbal medicine that was
shown to be superior to placebo in a small RCT. It is too early to determine
if this is an effective treatment or not, but the promising positive results
obtained suggest it is a good candidate for future research.

Summary

In summary, there are a number of drugs with strong evidence for the treat-
ment of PTSD as monotherapy or to augment pharmacological treatments.
Pharmacological and Other Biological Treatments 285

Fluoxetine, paroxetine, sertraline, and venlafaxine show strong evidence of

being effective, albeit low effect, treatments for PTSD, and there is emerg-
ing evidence that quetiapine is an effective monotherapy for PTSD. Prazosin
and risperidone have good evidence of being effective for the augmenta-
tion of other pharmacological treatment. There is an urgent requirement to
ensure that people with PTSD are offered optimal pharmacological treat-
ments based on the current evidence. It is also important that further work
be undertaken to better understand the neurobiology of PTSD and to use
this knowledge to identify better pharmacological treatments in the future.

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400–405.
Southwick, S. M., Bremner, J. D., Rasmusson, A., Morgan, C. A., Amsten, A., & Char-
ney, D. S. (1999). Role of norepinephrine in the pathophysiology and treatment
of PTSD. Biological Psychiatry, 46, 1192–1204.
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lines in psychiatry. London: Wiley-­Blackwell.
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1205–1212.
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health problems (11th rev.). Geneva, Switzerland: Author. Retrieved from https://
icd.who.int.
C H A P TE R 17

Combined Psychotherapy
and Medication Treatment
Mark Burton, Jessica Maples‑Keller, Mathew D. Hoskins,
Yilang Tang, Katarzyna Wyka, JoAnn Difede,
and Barbara O. Rothbaum

Torder
he literature supports several psychotherapeutic and pharmacological
approaches as first- and second-­line treatments for posttraumatic stress dis-
(PTSD). Meta-­analytic reviews consistently demonstrate that trauma-­
focused psychotherapies outperform wait-list control and placebo-­therapy
conditions in randomized clinical trials (Cusack et al., 2016; Lee et al., 2016;
Watts et al., 2013), with greater reductions in PTSD symptom severity that is
maintained after treatment ends (Kline, Cooper, Rytwinski, & Feeny, 2018).
Manualized, evidence-­based, trauma-­focused psychotherapies include pro-
longed exposure (PE), cognitive processing therapy (CPT), cognitive therapy
(CT), and eye movement desensitization and reprocessing (EMDR) therapy.
However, some patients will not achieve full response to psychotherapy for
PTSD. One strategy to improve outcome is to augment psychotherapy with
medication. Several medications demonstrate efficacy as monotherapies for
treating PTSD (Hoskins et al., 2015). Medication monotherapy for PTSD is
further described by Bisson, Hoskins, and Stein (Chapter 16, this volume).
The most recent U.S. Department of Veterans Affairs and Department
of Defense (VA/DoD) Clinical Practice Guideline for the Management of Post-
traumatic Stress Disorder and Acute Stress Disorder (2017) recommends manu-
alized, trauma-­focused psychotherapies, such as PE and CPT, as first-line
treatments and pharmacotherapy with sertraline, paroxetine, fluoxetine, or
venlafaxine recommended as second-­line treatments only for those who do
not choose or cannot access trauma-­focused therapy. The American Psy-
chological Association (2017) Clinical Practice Guideline for the Treatment of
PTSD also suggests that the evidence is strong for the recommendation of

287
288 Treatments for Adults

trauma-­focused psychotherapy as monotherapy for PTSD and that the evi-

dence is conditional for the use of sertraline, paroxetine, fluoxetine, and
venlafaxine. Likewise, the Posttraumatic Stress Disorder Prevention and Treat-
ment Guidelines formulated by the International Society for Traumatic Stress
Studies (ISTSS) recommend psychological treatments with a trauma focus
more strongly than pharmacotherapy. In terms of combination therapy, the
ISTSS guidelines did not include a scoping question to consider this. The
VA/DoD guidelines state there is insufficient evidence to suggest the addi-
tion of medication for psychotherapy nonresponders, the addition of psycho-
therapy for medication nonresponders, or the combination of medication
and psychotherapy from the start of treatment. Furthermore, they recom-
mend against augmentation of psychotherapy with antipsychotics, benzo-
diazepines, topiramate, divalproex, baclofen, and pregabalin, due to low-­
quality evidence, insufficient evidence, and known adverse effects of these
treatments. Augmentation of exposure therapy with d -cycloserine (DCS) is
recommended for research settings only. The American Psychological Asso-
ciation guidelines do not address combination treatment, citing a lack of
comparative effectiveness trials. In general, the literature supports multiple
trauma-­focused treatments and some medications as monotherapies for
PTSD. Although combination approaches are not as well studied, there is a
growing body of literature to inform clinical research moving forward.

Description of Techniques

The current chapter examines this literature and discusses research and clini-
cal practice issues related to combined psychotherapy and pharmacotherapy
for the treatment of PTSD. The studies reviewed are described in Table 17.1.
Our review is divided into two broad categories: (1) evidence for combin-
ing psychotherapy with empirically supported medications prescribed daily
as monotherapies for PTSD, such as selective serotonin reuptake inhibitors
(SSRIs), and (2) evidence for combining psychotherapy with acute-­acting
medications and interventions prescribed to enhance specific psychothera-
peutic processes, such as extinction learning and emotional engagement.
Such psychotherapy-­ specific adjunctive interventions discussed in this
chapter include d -cycloserine (DCS), methylene blue, yohimbine, proprano-
lol, dexamethasone, hydrocortisone, and repetitive transcranial magnetic
stimulation (rTMS). A novel psychotherapy that utilizes 3,4-methylenedioxy-­
methamphetamine (MDMA) as an adjunct is also discussed.

Summary of the Evidence

The literature for combination treatment is not as well developed as that

for monotherapies. However, there are a growing number of randomized
 TABLE 17.1. Reviewed Studies
Study
and methods Participants Outcomes Interventions Results Notes

Conventional medications plus therapy

Buhmann N = 280; mean age: 49 HTQ; • Group 1: Sertraline (25–200 No significant 54% of sessions were
et al. (2016); years; sex: 41% female; HSCL-25; mg, mean dose 132.1 mg) ± difference between translated; 25% in
Denmark; diagnosis: DSM-IV PTSD; HRSD; minaserin (10–30 mg, mean medication, therapy actually received
study type: predominant trauma type: HRSA; dose 20 mg); n = 71 psychotherapy, or exposure treatment;
pragmatic; asylum experience; mean SCL-90; • Group 2: Sertraline (25–200 combination on PTSD additionally, 27% of the
duration: 6 duration of symptoms: VAS; SDS; mg, mean dose 132.1 mg) ± symptoms. therapy group received
months 14.7 years WHO-5 minaserin (10–30 mg, mean another antidepressant.
dose 20 mg) plus therapy; n =
71
• Group 3: Therapy (16 sessions
CBT over 6 months); n = 70
• Group 4: Waiting list; n = 68

Hien et al. N = 69; mean age: 42.2; CAPS; • Group 1: Sertraline (50–200 Significant Medication titrated over
(2015); U.S.; sex: 81% female; diag- SCID-I; mg, mean dose not available) improvement in 2 weeks prior to therapy;
study type: nosis: DSM-IV-TR PTSD TLFB plus 12 weekly sessions of PTSD symptoms in patients had PTSD and
RCT; duration: and alcohol use disorder; Safety Seeking (SS) therapy; sertraline plus SS co-occurring alcohol use
12 weeks predominant trauma type: n = 32 group compared to disorder.
CSA (46%); mean dura- • Group 2: Placebo plus SS; n = placebo plus SS.
tion of symptoms: 14 years 37

Popiel et al. N = 228; mean age: 36.9 SCID-I; • Group 1: PE × 12 weekly Significant Max medication dose was
(2015); Poland; years; sex: unclear; diag­ PDS; BDI-II sessions; n = 114 improvement in PTSD achieved in 3–7 days after
study type: nosis: DSM-IV-TR PTSD; • Group 2: Paroxetine 20 mg × symptoms across all starting the trial and
RCT; duration: predominant trauma type: 12 weeks; n = 57 groups, with higher reduced within 2 weeks
12 weeks motor-vehicle accident • Group 3: PE plus paroxetine remission rates after following the 12-week
(100%); mean duration of 20 mg × 12 weeks; n = 57 PE alone compared to trial.

289
symptoms: 17.7 months paroxetine alone.
(continued)
 TABLE 17.1. (continued)

290
Study
and methods Participants Outcomes Interventions Results Notes

Rothbaum N = 65 (88 completed SIP; BDI; • Group 1: Sertraline 50–200 Sertraline plus PE Flexible dosing schedule
et al. (2006); 10-week open label); mean STAI-S mg × 10 weeks (mean dose was better than was used for Phase I
U.S.; study age: 39.3; sex: 64.6% 173.1 mg) open label followed sertraline alone for (0–10 weeks). Minor
type: RCT; female; diagnosis: DSM-IV by 5 weeks double-blind weaker medication adjustments in dose
duration: 16 PTSD; predominant sertraline plus 10 sessions of responders in post hoc allowed in weeks 6–10.
weeks trauma type: sexual twice-weekly PE; n = 34 analyses. No further adjustments
assault; mean duration of • Group 2: Sertraline 50–200 were permitted in Phase
symptoms: 8.1 years mg × 10 weeks open label II (Weeks 10–15).
followed by 5 weeks sertraline
alone; n = 31

Schneier et al. N = 37; mean age: 50.3 CAPS; • Group 1: Paroxetine (12.5–50 Greater PSTD symp- Paroxetine was dosed at
(2012); U.S.; years; sex: 54% female; HAMD; mg, mean dose 32.2 mg) plus tom reduction and 12.5 mg/day for Week 1,
study type: diagnosis: DSM-IV PTSD; QLESQ 10 weekly sessions of PE; higher remission rates then 25 mg/day for Week
RCT; duration: predominant trauma n = 19 in paroxetine plus 3, then increased dosage
10 weeks type: World Trade Center • Group 2: Placebo plus 10 PE group compared up to 50 mg/day as
attacks; mean duration of weekly sessions of PE; n = 18 to placebo plus PE at tolerated for remainder
symptoms: 6.5 years posttreatment; no dif- of trial. The sample
ferences at follow-up. consisted entirely of adult
survivors of the World
Trade Center attacks.

Simon et al. N = 68; mean age: 46 SPRINT; • Group 1: Paroxetine (12.5– No significant differ- Therapy course: eight
(2008): U.S.; years; sex: 56% female; CGI-S 62.5 mg) + PE; n = 9 ence between parox- sessions of open-label PE
study type: diagnosis: DSM-IV PTSD; • Group 2: Placebo + PE; n = 14 etine plus PE versus (90–120 minutes); non-
RCT; duration: predominant trauma type: placebo plus PE responders randomized
10 weeks physical and sexual abuse group, with a small to treatment arms; five
(78%); mean duration of trend toward greater sessions of double-blind
symptoms: unclear symptom reduction in PE plus paroxetine/
 placebo group. placebo (90–120 minutes,
fortnightly) × 10 weeks.

DCS-assisted therapy
de Kleine et N = 67; mean age: 38.3 CAPS; BDI; • Group 1: 50 mg DCS No significant No take-home DCS for
al. (2012); the years; sex: 80.6% female; STAI administered orally 1 hour difference between homework; concomitant
Netherlands; diagnosis: DSM-IV PTSD; prior to each face-to-face DCS plus exposure psychotropics were
study type: predominant trauma type: session of manualized PE; and placebo plus allowed.
RCT; duration: sexual abuse (52%); mean n = 33 exposure, with
10 weeks duration of symptoms: • Group 2: Administered orally greater symptom
unknown 1 hour prior to each face-to- reduction in those
face session of manualized PE; with more severe
n = 34 pretreatment PTSD in
post hoc analyses.

Difede et al. N = 25; mean age: 45.8 CAPS; • Group 1: 12 weekly sessions of Significantly greater Pharmacotherapy (on a
(2014); U.S.; years; sex: 24% female; SCID- CBT, including PE enhanced remission rates stable dose for 2 months)
study type: diagnosis: DSM-IV PTSD; MDD; by virtual reality (VRE) with in DCS plus VRE allowed during therapy.
RCT; duration: predominant trauma BDI-II; 100 mg DCS 90 min before compared to placebo
12 weeks type: World Trade Center STAXI-2; Sessions 2–11; n = 13 plus VRE.
attacks; mean duration of PCL • Group 2: 12 weekly sessions of
symptoms: unclear CBT, including PE enhanced
by VRE with placebo 90 min
before Sessions 2–11; n = 12

Litz et al. N = 26; mean age: 32 CAPS; BDI • Group 1: 6 weekly exposure Significantly less Trial stopped before
(2012); U.S.; years; sex: 100% male; sessions with 50 mg DCS symptom reduction planned recruitment of
study type: diagnosis: DSM-IV PTSD; given 30 min prior to Sessions in DCS plus exposure 68 was reached.
RCT; duration: predominant trauma type: 2–5; n = 13 group compared
6 weeks combat; mean duration of • Group 2: 6 weekly exposure to placebo plus
symptoms: unclear sessions with placebo given exposure.
30 min prior to Sessions 2–5;

291
n = 13
(continued)
292
TABLE 17.1. (continued)
Study
and methods Participants Outcomes Interventions Results Notes

Rothbaum et N = 106; mean age: 34.6 CAPS; • Group 1: 6 weekly 90- min Significant 56% were on a stable
al. (2014); U.S.; years; sex: 6% female; startle VRE sessions with DCS 50 mg improvement in PTSD dose of psychotropic
study type: diagnosis: DSM-IV PTSD; response; given 30 min prior to each symptoms across all medications.
RCT; duration: predominant trauma type: salivary session; n = 53 VRE groups, but no
6 weeks combat (100%); mean cortisol • Group 2: 6 weekly 90-min significant difference
duration of symptoms: VRE sessions with alprazolam between DCS and
unknown given 30 min prior to each placebo; DCS group
session; n = 50 showed significantly
• Group 3: 6 weekly 90-min greater improvements
VRE sessions with placebo on startle and salivary
given 30 min prior to each cortisol maintained at
session; n = 53 follow-up.

MDMA-assisted therapy
Mithoefer et N = 23; mean age: 40.4 CAPS; • Group 1: 12 therapy sessions Significant MDMA-assisted therapy
al. (2011); U.S.; years; sex: 85% female; IES-R; with 125 mg MDMA given improvement in PTSD model includes male–
study type: diagnosis: DSM-IV PTSD; SCL-90-R; prior to Sessions 3 and 8; symptoms and rates female therapist dyad;
RCT; duration: predominant trauma type: RBANS; n = 15 of clinical response drug-assisted sessions
12 weeks crime related (95%); mean PASAT; • Group 2: 12 therapy sessions in MDMA group last 6–8 hours, are
duration of symptoms: 19 RCFT with placebo given prior to compared to placebo. nondirective, and
years Sessions 3 and 8; n = 8 include music, eye mask,
and overnight stay; all
participants were deemed
to be treatment-resistant.
 Mithoefer et N = 24; mean age: 37.2 CAPS-IV; • Group 1: 12 therapy sessions Significant MDMA-assisted therapy
al. (2018); U.S.; years; sex: 27% female; BDI-II; with 30 mg (active placebo) improvement in PTSD model includes male–
study type: diagnosis: DSM-IV PTSD; PSQI; MDMA given prior to Sessions symptoms and rates female therapist dyad;
RCT; duration: predominant trauma type: PTGI; 4 and 8; n = 7 of clinical response in drug-assisted sessions
12 weeks service personnel; mean NEO-PI-R; • Group 2: 12 therapy sessions MDMA groups (with last 6–8 hours, are
duration of symptoms: DES-II; with 75 mg MDMA given 75 mg being greatest) nondirective, and
85.4 months GAF; prior to Sessions 4 and 8; n = 7 compared to active include music, eye mask,
C-SSRS • Group 3: 12 therapy sessions placebo. and overnight stay; all
with 125 mg MDMA given participants were deemed
prior to Sessions 4 and 8; to be treatment-resistant.
n = 12

Oehen et al. N = 14; mean age: 41.4 CAPS; PDS • Group 1: 12 therapy sessions Significant MDMA-assisted therapy
(2013); years; sex: 83% female; with 25 mg (active placebo) improvement in model includes male–
Switzerland; diagnosis: DSM-IV PTSD; MDMA given prior to Sessions PTSD symptoms on female therapist dyad;
study type: predominant trauma 3 and 8; n = 5 self-reported but drug-assisted sessions
RCT; duration: type: CSA (50%); mean • Group 2: 12 therapy sessions not clinically rated last 6–8 hours, are
12 weeks duration of symptoms: with 125 mg (active placebo) measures in MDMA nondirective, and
18.3 years MDMA given prior to Sessions group compared to include music, eye mask,
3 and 8; n = 9 placebo. and overnight stay; all
participants were deemed
to be treatment-resistant.

(continued)

293
294
TABLE 17.1. (continued)
Study
and methods Participants Outcomes Interventions Results Notes

Other agents
Brunet et N = 61; mean age: 39.4 CAPS; • Group 1: 6 weekly trauma Significant Brief intervention; first
al. (2018); years; sex: 58% female; PCL-S memory reactivation sessions improvement in session 30 min of written
Canada; study diagnosis: DSM-IV-TR with propranolol (0.67 mg/ PTSD symptoms in narrative; subsequent
type: RCT; PTSD; predominant kg short-acting plus 1 mg/kg propranolol group sessions 10–20 min.
duration: 6 trauma type: physical long-acting preparations with compared to placebo.
weeks and sexual (57%); mean food); n = 30
duration of symptoms: • Group 2: 6 weekly trauma
unknown memory reactivation sessions
with placebo; n = 30

Tuerk et al. N = 26; mean age: 32.4 Trauma- • Group 1: Yohimbine 21.6 mg No significant The sample consisted
(2018); U.S.; years; sex: 100% male; cued taken 1 hour prior to each PE difference in entirely of male, post-
study type: diagnosis: DSM-IV PTSD; heart rate session; n = 14 posttreatment PTSD 9/11 combat veterans.
RCT; duration: predominant trauma type: reactivity; • Group 2: Placebo taken 1 symptom severity or
15 weeks combat; mean duration of PCL-M; hour prior to each PE session; remission.
symptoms: unclear BDI-II n = 12

Zoellner N = 42; mean age: 37.5 PSS-I; CGI; • Group 1: 6 sessions of Significantly Treatment was modified
(2017); U.S.; years; sex: 100% female; SCID-IV; imaginal exposure (IE) plus enhanced treatment from the PE manual and
study type: diagnosis: DSM-IV-TR PSS-SR; 260 mg methylene blue (MB) response and quality included daily imaginal
RCT; duration: PTSD; predominant QIDS-SR; administered post-IE; n = 15 of life in MB plus IE exposures with no in vivo
 6 weeks trauma type: physical PTCI; • Group 2: 6 sessions of IE plus compared to placebo exposures.
assault (28.6%); mean OSPAN; placebo administered post-IE; group.
duration of symptoms: SF-36 n = 16
unclear SUDS; MEF • Group 3: Waiting list; n = 11

Kozel et al. N = 103; mean age: 31 CAPS; • Group 1: Cognitive processing Greater symptom The sample consisted of
(2018); U.S.; years; sex: 100% male; PCL; therapy (CPT) plus repetitive reduction across both male and female post-
study type: diagnosis: DSM-IV PTSD; M-PTSD; transcranial magnetic clinician-rated and 9/11 combat veterans.
RCT; duration: predominant trauma type: QIDS; IPF stimulation (rTMS); n = 54 self-reported PTSD The rTMS stimulator coil
15 weeks combat (100%); mean • Group 2: CPT plus sham symptoms in CPT was positioned over the
duration of symptoms: rTMS; n = 49 plus rTMS compared dorsolateral prefrontal
unclear to sham group. cortex at 110% of motor
threshold at 1hz rTMS
continuously for 30
minutes for a total of
1,800 pulses immediately
prior to CPT session.

Note. BDI, Beck Depression Inventory; CAPS, Clinician-Administered PTSD Scale; CGI-S, Clinical Global Impression Severity; CSS, Crisis Support Scale; C-SSRS,
Columbia-Suicide Severity Rating Scale; DES-II, Dissociative Experiences Scale II; GAF, Global Assessment of Functioning; HAMA, Hamilton Rating Scale for Anxi-
ety; HAMD, Hamilton Rating Scale for Depression; HRSA, Hamilton Rating Scale for Anxiety; HRSD, Hamilton Rating Scale for Depression; HSCL-25, Hopkins
Symptom Checklist-25; HTQ, Harvard Trauma Questionnaire; IES-R, Impact of Event Scale Revised; IPF, Inventory of Psychosocial Functioning; MEF, Medication
Effects Form; M-PTSD, Mississippi Scale for Combat-­Related PTSD; NEO-PI-R, Neuroticism–Extroversion–Openness–Personality Inventory—Revised; OSPAN, Auto-
mated Operation Span; PASAT, Paced Auditory Serial Addition Task; PCL-M, Posttraumatic Stress Checklist—Military Version; PCL-S, PTSD Checklist-Specific; PDS,
Posttraumatic Diagnostic Scale; PSQI, Pittsburgh Sleep Quality Index; PSS-I, PTSD Symptom Scale—Interview Version; PSS-SR, PTSD Symptom Scale—Self-Rated Ver-
sion; PTCI, Post-Traumatic Cognitions Inventory; PTGI, Post-Traumatic Growth Inventory; QIDS-SR, Quick Inventory of Depressive Symptoms—Self-Rated; QLESQ,
Quality of Life Enjoyment and Satisfaction Questionnaire; RBANS, Repeatable Battery for the Assessment of Neuropsychological Status; RCFT, Rey–Osterrieth Com-
plex Figure; SAS-SR, Social Adjustment Scale Self-Report; SCID-I, Structured Clinical Interview for DSM-IV-TR Axis I Disorders; SCID-I, Structured Clinical Interview
for DSM-IV; SCL-90, Symptom Checklist-90; SDS, Sheehan Disability Scale; SF-36, Short Form Health Survey; SIP, Structured Interview for PTSD; SPRINT, Short
PTSD Rating Interview; STAI-S, State–Trait Anxiety Inventory–State Portion; STAXI-2, State–Trait Anger Expression Inventory-2; SUDS, Subjective Units of Distress;
TLFB, Timeline Follow-Back; VAS, Visual Analogue Pain Scales; WHO-5, WHO-Five Well-Being Index.

295
296 Treatments for Adults

controlled trials (RCTs) examining incremental benefits for medications

combined with evidence-­based psychotherapy. This chapter will critically
review the evidence for combination treatments, specifically focused on
randomized clinical trials that compare combination approaches to either
medication alone or psychotherapy alone.
Several types of trials have examined the effects of combination treat-
ment. The first type randomizes individuals to evidence-­ based psycho-
therapy with either an active medication adjunct or placebo. This method
provides a test of the effects of combining medication and psychotherapy
from the start of treatment and has been applied to the study of daily-dosed
medications like SSRIs and novel psychotherapy augmentation agents. The
second type of trial involves maintaining all individuals in a sample on a
monotherapeutic medication for a given duration, then randomizing indi-
viduals to either receive adjunctive psychotherapy or continue medication
only. This method allows for a clinically relevant analysis of the benefits of
adding psychotherapy for individuals who already are on a medication. The
third type of trial involves providing individuals with a course of psycho-
therapy, then adding a medication or placebo. The current chapter outlines
studies utilizing each of these methodological approaches and discusses
their clinical implications.

Combining Efficacious Monotherapies

Several studies have examined combination treatment of evidence-­based
monotherapeutic medications and psychotherapy for adults with PTSD.
The first combination study conducted by Rothbaum and colleagues (2006)
examined the benefits of adding evidence-­ based psychotherapy (PE) to
ongoing sertraline treatment for a sample of 88 civilians diagnosed with
PTSD mostly related to assault. In Phase I, all participants were started on
open-label sertraline treatment for 10 weeks. Medication was titrated up to
200 mg/day or the maximum tolerated dose over the first 6 weeks, with
minor adjustments allowed until Week 10 and maintenance of dosage there-
after. Phase II of the study was conducted from Week 10 to Week 15. In
this phase, participants with at least a 20% reduction in PTSD severity were
randomized to either start PE in conjunction with sertraline (n = 34) or con-
tinue sertraline only for 5 weeks (n = 31). PE was provided in twice-­weekly,
90- to 120-minute sessions for a total of 10 sessions. PTSD, depression, and
state anxiety severity were measured at Week 0, Week 10 (post–Phase I),
and Week 15 (post–Phase II). Results showed that both those who went on
to receive sertraline-­only in Phase II and those who received sertraline plus
PE had equal reductions in PTSD symptoms across Phase I, as expected
given that they were both receiving monotherapy with sertraline. During
the second phase, PTSD symptom severity continued to decrease for those
randomized to combined medication treatment with PE, while it leveled out
for those who continued sertraline-­only treatment (Week 15 between-­g roup
Combined Psychotherapy and Medication Treatment 297

d = 0.38).1 For depression and state anxiety, symptom severity reduced from
Week 0 to Week 10, but not from Week 10 to 15, with no significant differ-
ence found between treatment groups (Week 15 combined within-­g roup d =
1.26 and 1.10, respectively).
Secondary analyses comparing treatment outcomes in high responders
to sertraline-­only treatment (Phase I) and partial responders showed that
high responders continued to see reductions in PTSD symptoms in Phase
II of treatment regardless of whether they received additional combination
PE or stayed on sertraline only (Week 15 between-­g roup d = –0.18). How-
ever, for partial responders in Phase I, further reductions in PTSD severity
in Phase II were only found for those who received combination treatment
(Week 15 between-­g roup d = 0.90). Taken together, these findings suggest
that adding PE to sertraline treatment may be indicated for those who do
not fully respond to medication alone. Notably, this study did not include a
placebo control condition in Phase I or an evidence-­based control therapy in
Phase II. As such, findings cannot elucidate specific mechanisms for clinical
improvement.
Simon and colleagues (2008) examined the benefits of adding medica-
tion to ongoing psychotherapy for PTSD due to mixed trauma. This trial
started 44 adult participants on psychotherapy (PE) and then added medi-
cation (paroxetine). Specifically, during Phase I, all participants received
eight sessions of PE over 4–6 weeks and were then randomized to receive
combination treatment with paroxetine (n = 9) or a placebo control (n = 14)
in the second phase while continuing to receive PE (five sessions). Only indi-
viduals who were designated as nonremitters after Phase I were randomized
to Phase II (n = 23). Strong effects were found for PE as a monotherapy in
Phase I, with significant mean reductions in PTSD symptom severity. Thirty-­
eight percent of the sample met full PTSD remission status (<6 on the Short
PTSD Rating Interview; Davidson et al., 2001). Twenty-­five individuals did
not fully remit and were thus randomized to receive either paroxetine or
placebo. Paroxetine was initiated at 12.5 mg/day and titrated according to
tolerability up to a maximum dose of 62.5 mg/day for 10 weeks. The mean
end-point medication dose for paroxetine was 45.8 mg/day (SD = 16.5 mg/
day) compared to 44.8 mg/day (SD = 15.5 mg/day) for placebo. Medication
was given in combination with PE, which was provided at a lower frequency
in Phase II compared to Phase I (every 2 weeks compared to twice per week).
Phase II results showed no significant difference in PTSD symptom severity
between the paroxetine and placebo groups at the end of treatment (Weeks
14–16 between-­g roup d = 0.35). Remission rates by the end of Phase II for
this treatment refractory group were low, with 3/9 (33%) of those receiving

1 Between-­
g roup effect sizes were calculated when not provided in the original manu-
script using Cohen’s d formula, d = mean 1 – mean 2/pooled standard deviation, and are
denoted in the text with an asterisk (*). There was insufficient data to calculate within-­
group effect sizes when they were not reported in the manuscript.
298 Treatments for Adults

paroxetine and 2/14 (14%) of those receiving placebo demonstrating remis-

sion.
These two clinical trials examined benefits of adding a second interven-
tion after an unsuccessful course of monotherapy. Although these studies
suggest a benefit for adding PE for low responders to sertraline, method-
ological limitations, including small sample sizes (e.g., N = 44 in Simon et al.,
2008) and the lack of placebo controls for therapy and medication, make it
difficult to draw broad, clinically applicable conclusions.
In a third trial, Schneier and colleagues (2012) tested the idea that start-
ing combination therapy from the initiation of treatment would be more
effective than PE alone for treating PTSD for survivors of the World Trade
Center terrorist attacks on September 11, 2001. Thirty-­seven participants
were randomized to receive 10 weekly sessions of PE with paroxetine (n =
19) or placebo (n = 18). Paroxetine was initiated at 12.5 mg/day and titrated
according to tolerability to a maximum dose of 50 mg/day. Average final
dose for the combined group was 32.2 mg/day (SD = 13.4) and 36.8 mg/day
(SD = 12.1) for the paroxetine equivalent in the placebo group. Participants
could choose to continue medication (or placebo) after the end of PE for
up to 12 weeks. Results showed that those who received paroxetine demon-
strated better treatment response compared to those who received placebo,
with greater reductions in PTSD symptom severity (Week 10 between-­g roup
d = 1.66*), higher remission rates (42.1% vs. 16.7%), and greater improve-
ments in quality of life (Week 10 between-­g roup d = 0.75*). Depression sever-
ity was lower for the combination group (Week 10 between-­g roup d = 0.82*),
although this difference was not statistically significant. For those who con-
tinued on double-­blinded medication (n = 13) or placebo (n = 13) for the
maintenance period after PE was discontinued, no additional gains were
made, and PTSD symptom severity did not differ between groups after the 12
extra weeks of medication maintenance (Week 22 between-­g roup d = 0.37).
One individual who was a remitter at Week 10 became a nonaremitter at
Week 22, four individuals discontinued before Week 22, and the rest either
maintained or gained remitter status in the maintenance phase. Notably,
sample size was small and patients were not randomly selected for the sec-
ond phase, which could have impacted the treatment differences identified.
Future research with improved power can determine if this advantage of
combined treatment persists over long follow-­up time points.
A more recent trial examined the benefits of combined PE and parox-
etine treatment in a sample of 228 motor-­vehicle crash (MVC) survivors (Pop-
iel, Zawadzki, Praglowska, & Teichman, 2015). MVC survivors diagnosed
with PTSD were randomized to receive either PE alone (n = 144), paroxetine
alone (n = 57), or combination treatment (n = 57). Treatment was adminis-
tered over 12 weeks. PE was based on the standard protocol of one 90-minute
session per week. The medication-­only condition included 45-minute meet-
ings with a psychiatrist every 2 weeks for medication and symptom monitor-
ing and support. Medication was titrated up through Week 7 to a maximum
Combined Psychotherapy and Medication Treatment 299

dose of 20 mg/day. Of note, a study limitation included that the dose of

paroxetine was a lower maximum than in other combination studies and the
authors did not report the mean and standard deviation of dosing for their
sample. The combination group received treatment from PE-­trained psy-
chiatrists who provided additional 15-minute medication management ses-
sions after PE every 2 weeks. Results of the modified intent to treat analyses
(n = 179 participants who started treatment) indicated that PTSD remission
rates were significantly higher for the PE group (80.8%) compared to the
medication-­only group (56.6%), but no significant differences were found
for the combination group compared to either of the monotherapy groups
(76.9%). Among treatment refusers (n = 49), rates of refusal were higher in
the medication-­only (47.4%) and combination (31.6%) groups compared to
the PE group (3.5%), possibly indicating a preference for starting PE as a
monotherapy.
Two additional trials examined the efficacy of combining sertraline
and PE from treatment inception. Rauch and colleagues (2019) randomized
223 post-9/11 veterans of the Iraq or Afghanistan wars with combat-­related
PTSD to combination treatment (PE plus sertraline; n = 75), PE plus placebo
(n = 74), or sertraline plus enhanced medication management (n = 74). Par-
ticipants, recruited across four sites, were randomized to receive treatment
over 24 weeks. PE participants received up to 13 standard sessions. Sertra-
line dosing was adjusted between 50 mg/day and 200 mg/day and titrated
upward through Week 10 and then maintained across the 24-week study
period. Average dose by the end of treatment for PE plus sertraline, PE plus
placebo, and sertraline plus enhanced medication management was 171.6
(SD = 45.0), 197.4 (SD = 11.3), and 170.7 (SD = 46.9), respectively. Enhanced
medication management included medical management, psychoeducation,
and active listening. Discussion of trauma-­related details and guidance on
addressing PTSD symptoms were not permitted in medication management
sessions. To monitor this, all sessions were taped and 20% were randomly
selected for review, with 96.7% of reviewed tapes demonstrating adherence
to session protocol. Results indicated that PTSD symptoms reduced signifi-
cantly, on average, for all study participants with no significant differences
found between study conditions (Week 24 between-­g roup d = 0.38 for PE
plus placebo vs. sertraline plus enhanced medication management; d = 0.28
for PE plus placebo vs. PE plus sertraline). Notably, the medication manage-
ment in this protocol was enhanced compared to standard medication man-
agement, which may be associated with positive results in this group.
Feeny, Mavissakalian, Roy-Byrne, Bedard-­Gilligan, and Zoellner (2020)
compared PE plus sertraline to PE alone (without a placebo) in a trial exam-
ining the effect of choice (i.e., being allowed to choose your treatment) on
treatment outcome for a civilian population. In a doubly randomized prefer-
ence trial, 150 participants across two sites were first randomized to choice
or no- ­choice groups. Those in the choice group could choose whether they
received PE alone or in combination with sertraline. Those in the no-­choice
300 Treatments for Adults

group were randomized to a treatment condition. Standard PE was provided

over 10 weekly sessions. Sertraline was dosed as low as 25 mg/day at Week 1
and titrated up to a maximum of 200 mg/day. Analyses are currently being
conducted for this recently completed trial. It is expected that the trial will
inform clinical recommendations for combining PE and sertraline for the
treatment of PTSD, as well as the role of preference and choice in treatment
outcome.
Few trials have examined the effects of combination PTSD treatment
in which the psychotherapy component was not PE. One study randomized
280 refugees with war-­related PTSD to receive an antidepressant medication
alone (either sertraline or the tetracyclic antidepressant, mianserin; n = 71),
psychotherapy alone (n = 70), these treatments in combination (n = 71), or
to remain in a wait-list control condition (n = 68) (Buhmann, Nordentoft,
Ekstroem, Carlsson, & Mortensen, 2016). The psychotherapy component
was described as “flexible,” allowing clinicians to choose from multiple CBT
components, such as mindfulness and cognitive methods. Only 19% of par-
ticipants received any exposure component, while 7% received exposure
more than three times, which was reportedly related to both patient prefer-
ence and therapist reluctance. The mean duration of treatment was approxi-
mately 6 months for all four groups. No effect on PTSD symptoms or depres-
sive symptoms was demonstrated for any of these treatments (between-­g roup
d < 0.32). The psychotherapy offered was of moderately short duration,
which may have impacted the results. A similar study showed an effect for
“flexible” treatment in combination with medication (venlafaxine vs. sertra-
line) for refugees (Sonne, Carlsson, Bech, Elklit, & Mortensen, 2016). Treat-
ment included a total of 10 sessions with a psychiatrist or medical doctor and
16 sessions with a psychologist and optional individual, as well as group ses-
sion with social workers (the average number of social work sessions was not
included in the original manuscript). No effect on PTSD or depressive symp-
toms was found between the sertraline and venlafaxine group (between-­
group d < 0.22). Importantly, since the study did not have a monotherapy
comparison, the results cannot address the incremental benefits of combi-
nation treatment. Additionally, patient and clinical staff were not blind to
treatment conditions and there was no placebo control or wait-list group, so
it was not possible to compare the effects of pharmacological treatments to
a control condition. Finally, Hien and colleagues (2015) examined the effects
of adding sertraline (n = 32) versus placebo (n = 37) for 69 individuals receiv-
ing Seeking Safety (SS), a manualized treatment for mixed-­trauma PTSD
and comorbid alcohol use disorder (Najavitz, 2002). Results showed larger
reductions in PTSD symptoms at posttreatment (Week 12 between-­g roup
d = 0.83) and follow-­up (6- and 12-month between-­g roup d = 0.71 and d =
0.65, respectively) for those receiving sertraline compared to placebo. These
findings may be difficult to generalize because not all participants met full
diagnostic criteria for PTSD, and the treatment, which lacks robust empiri-
cal support, was reduced to half the typical course of sessions.
Combined Psychotherapy and Medication Treatment 301

Thus, the extant literature does not demonstrate compelling evidence

for the addition of SSRI medications to psychotherapy based on a limited
number of RCTs and mixed study designs. Further research in this area is
needed.

Novel Augmentation Strategies

Novel pharmacological and physiological approaches that can catalyze the
psychotherapeutic process offer an alternative strategy to traditional addi-
tive combination therapies. Currently, multiple approaches are in the early
stage of investigation, including DCS, MDMA, methylene blue, yohimbine,
propranolol, hydrocortisone, dexamethasone, and rTMS.

d ‑Cycloserine

d -Cycloserine (DCS) is a partial NMDA receptor agonist. In animal mod-

els, DCS has been shown to facilitate the extinction of fear (Davis, Ressler,
Rothbaum, & Richardson, 2006), and has thus been studied as an adjunc-
tive medication to improve exposure-­based psychotherapy. A 2017 system-
atic review and meta-­analysis of 21 human studies showed a positive DCS
augmentation effect on exposure-­based cognitive-­behavioral therapy (CBT)
for anxiety, obsessive–­compulsive disorder (OCD), and posttraumatic stress
disorder (Mataix-­Cols et al., 2017). However, the effect was small (k = 21,
n = 1,047, mean difference = –3.62 [–0.81 to –6.43], d = –0.25) and may
be highly dependent on the number of DCS doses and timing as well as
baseline symptom severity. No differences were found between diagnoses. A
subsequent reanalysis showed that DCS effects were optimal when medica-
tion was received at least 60 minutes prior to treatment as compared to less
than 60 minutes before treatment (Rosenfield et al., 2019). A recent unpub-
lished meta-­analysis of four DCS trials for PTSD specifically suggested no
significant benefit for DCS over placebo as an augmentation strategy for the
treatment of PTSD (k = 4, n = 224, SMD = –0.07 [–0.52, 0.39]; Hoskins et al.,
2020).
Findings from individual PTSD studies are mixed. Specifically, the
effect of DCS augmentation of exposure-­based therapies in PTSD has been
evaluated in four published RCTs (de Kleine, Hendriks, Kusters, Broekman,
& van Minnen, 2012; Difede et al., 2014; Litz et al., 2012; Rothbaum et al.,
2014) and a fifth recently completed, unpublished trial (Difede, Rothbaum,
Rizzo, Roy, & Reist, 2019). The study by de Kleine and colleagues (2012)
randomized 67 mostly female sexual abuse survivors with PTSD to receive
either 50 mg DCS (n = 33) or placebo (n = 34) 60 minutes prior to prolonged
exposure (PE). PE included 8–10 weekly sessions lasting 90 minutes. There
was adequate random sequence generation, allocation concealment, and
blinding of participants, personnel, and outcome assessors. However, this
study allowed the use of concomitant psychotropic medications and there
302 Treatments for Adults

was incomplete outcome data, with data missing from more than 40% of
randomized participants.
PTSD symptoms reduced across time for the sample as a whole, but
treatment group (DCS vs. placebo) did not have a significant effect on slope
of change (Week 10 between-­g roup d = 0.43*). However, treatment group was
significantly associated with responder status (there was at least a 10-point
drop on CAPS), with those receiving DCS more likely to be responders at the
end of treatment (63.6%) compared to the placebo group (38.2%). Further-
more, exploratory session analyses indicated that DCS resulted in greater
symptom reduction in participants with greater baseline PTSD severity who
required more treatment sessions. Dropout rates were 27.3% in the DCS
group and 38.2% in the placebo group.
Difede and colleagues (2014) randomized 25 mostly male survivors of
the World Trade Center attacks to receive virtual reality exposure (VRE) plus
100 mg DCS (n = 13) or placebo (n = 12). The manualized VRE intervention
included 12 weekly, 90-minute sessions with DCS or placebo administered
90 minutes prior to the session. All dropouts from the study were reported,
and all from the placebo group (12% of randomized participants). However,
this study allowed the use of concomitant psychotropic medications. Partici-
pants, personnel, and outcome assessors were adequately blinded, and there
were small sample sizes per arm.
DCS showed a trend for greater symptom reduction at posttreatment
(Week 10 between-­g roup d = 0.68) and a significant reduction in symptoms
at 6-month follow-­up (between-­g roup d = 1.13) as well as increased PTSD
remission rates (Week 10, 46% vs. 8%; 6-month follow-­up 69% vs. 17%).
There were no DCS dropouts, compared to 25% in the placebo group.
Litz and colleagues (2012) randomized 26 male Iraq and Afghanistan
veterans with combat-­ related PTSD to receive a brief six-­ session, manu-
alized exposure therapy plus 50 mg DCS (n = 13) or placebo (n = 13) 30
minutes beforehand. In contrast with previous findings, the DCS group
demonstrated less symptom reduction than the placebo group (Week 6
between-­g roup d = 1.15*). Remission rates at posttreatment were similar
(33.3% vs. 36.4%). Dropout rates were 30.8% in the DCS group and 15.4%
in the placebo group. There was adequate random sequence generation and
allocation concealment, and outcome assessments were conducted by an
independent blind rater. However, the method of blinding participants and
personnel was not adequately described. Also, the trial was stopped before
the planned recruitment of n = 68 was reached, leaving a small sample size
per arm. There is some question if adequate extinction of fear occurred in
the psychotherapy sessions in the study.
Rothbaum and colleagues (2014) randomized 156 mostly male Iraq and
Afghanistan veterans with combat-­related PTSD in a three parallel-­a rmed
study to compare 50 mg DCS (n = 53), 0.25 mg alprazolam (n = 50), and
placebo prior to VRE (n = 53). The manualized VRE intervention included
six weekly 90-minute sessions with the experimental medication given 30
minutes beforehand. Concomitant psychotropics were allowed during this
Combined Psychotherapy and Medication Treatment 303

study. The random sequence generation and blinding of participants, per-

sonnel, and outcome assessors were not adequately described, and there was
a high dropout rate, with data missing for more than 40% of randomized
participants, with nearly a third being from participants who had dropped
out before their first treatment.
PTSD symptom severity significantly decreased for all groups. No sig-
nificant differences in PTSD symptom severity between the DCS and pla-
cebo groups were identified, but the alprazolam group had significantly
worse severity of symptoms than the placebo group at posttreatment. Remis-
sion rates at posttreatment were similar (21.4% vs. 25.7% vs. 26.5%). The
DCS group demonstrated enhanced between-­ session extinction learning
and demonstrated lower cortisol and startle reactivity to virtual trauma cues
at posttreatment. Dropout rates were high (DCS 45%, alprazolam 30%, pla-
cebo 36%), but occurred generally before the first treatment session (20%
of the sample). These findings provide converging evidence that benzodi-
azepines are not effective medications for PTSD, especially when combined
with exposure therapy.
Finally, Difede and colleagues (2019) randomized 192 mostly male com-
bat veterans to 50 mg DCS or placebo combined with VRE or PE treat-
ments for combat-­related PTSD. The manualized VRE intervention included
nine weekly sessions lasting 90 minutes. Sessions 3–9 included experimen-
tal medication given 30 minutes beforehand. All patients in all conditions
improved significantly at posttreatment and maintained their gains at fol-
low-­up. The main effect of DCS was not significant, suggesting that par-
ticipants improved at a similar rate regardless of medication. Dropout rates
were 26.3% in the DCS group compared to 36.1% in the placebo group.
In summary, although the findings across studies are suggestive of a
DCS effect on exposure-­based therapy (Mataix-­Cols et al., 2017; Rosenfield
et al., 2019), single studies of PTSD treatment were likely underpowered to
detect such an effect, given that all participants were randomized to receive
a known effective treatment. Detecting an effect is likely obscured by dif-
ferences in trauma type, number of treatment sessions received, and the
dosage and timing of DCS. For example, a recent meta-­analysis (Hoskins et
al., 2020) found that a higher dose of 100 mg DCS was more effective in one
RCT (de Kleine et al., 2012). Likewise, when timing is isolated in two RCTs
(de Kleine et al., 2012; Difede et al., 2014), giving 50–100 mg DCS 90 minutes
before therapy is modestly more effective than placebo (kappa = 2, n = 92,
SMD = –0.47 [–0.89, –0.06]). The single positive RCT suggests that further
research, in the direction of higher DCS doses given at longer intervals prior
to exposure-­based therapies, is needed to establish the clinical utility of this
augmentation strategy for the treatment of PTSD.

3,4‑Methylenedioxy‑methamphetamine
3,4-Methylenedioxy-­
methamphetamine (MDMA) is a ring-­ substituted
phenethylamine with a unique psychopharmacological profile, typically
304 Treatments for Adults

characterized by 2–6 hours of subjective feelings of well-being, sociability,

and positive mood. MDMA exerts its effect mainly through both an increased
release and reuptake inhibition of presynaptic serotonin and, to a lesser effect,
dopamine. MDMA is associated with a robust release of the neuropeptide
oxytocin and is associated with prosocial subjective experiences in healthy
controls. MDMA stimulates release of cortisol and noradrenaline, which may
enhance both emotional engagement and extinction learning (Young et al.,
2017). Given its potential to reduce fear responding, enhance fear extinc-
tion, and increase prosocial emotional states, MDMA has been proposed as
a candidate for assisting psychological therapies in traumatized people. The
effects of MDMA-­assisted psychotherapy (MDMA-AP) have been evaluated in
three published RCTs with small sample sizes (Mithoefer, Wagner, Mithoefer,
Jerome, & Doblin, 2011; Mithoefer et al., 2018; Oehen, Traber, Widmer, &
Schnyder, 2013) and one long-term follow-­up study (Mithoefer et al., 2013).
A novel MDMA-­ assisted therapeutic approach was developed and
manualized by the nonprofit Multidisciplinary Association for Psychedelic
Studies (MAPS), which includes a female–­ male therapist dyad, weekly
90-minute preparation and integration sessions, and two to three 8-hour-
long, drug-­ assisted sessions. During the drug-­ assisted sessions, the par-
ticipants are encouraged to focus their attention inward. The sessions are
self-­directed and unstructured, with participants allowed to think and talk
about their trauma spontaneously. However, specific discussion of trauma
can be encouraged by the therapist when needed. An initial pilot study of six
patients with PTSD due to a sexual assault provided support for the safety
and tolerability of this approach (Bouso, Doblin, Farre, Alcazar, & Gomez-­
Jarabo, 2008). In a small randomized trial of mostly female participants (n
= 20) with treatment-­resistant PTSD who received 16 weeks of manualized
MAPS MDMA-AP with two 8-hour sessions of either 125 mg MDMA (plus a
supplemental dose of 62.5 mg after 2 hours; n = 12) or matching inactive pla-
cebo (n = 8), the MDMA group demonstrated greater improvement in PTSD
symptoms than the placebo group (Mithoefer et al., 2011). There was ade-
quate random sequence generation and allocation concealment, although a
high risk of performance bias existed, with participants and personnel likely
unblinded by the novel nature of the drug. However, independent blinded
outcome assessors were used. The clinical response, defined as more than
30% reduction in CAPS, was achieved in 83.3% of the MDMA group, com-
pared to 25% of the placebo group, indicating that the MDMA-AP benefited
this small treatment-­resistant population. Clinical gains were largely main-
tained at 2- to 4-year follow-­up (Mithoefer et al., 2013).
As MDMA demonstrates acute effects likely noticeable compared to
placebo, maintaining the blind complicates the interpretation of results.
As such, a subsequent investigation compared two doses of MDMA. In a
randomized trial of 12 mostly female participants with chronic, treatment-­
resistant PTSD, participants received MDMA-AP via three drug-­assisted ses-
sions and either 125 mg MDMA (plus 62.5 supplemental dose; n = 8) or active
placebo 25 mg MDMA (plus 12.5 mg supplemental dose; n = 4). A significant
Combined Psychotherapy and Medication Treatment 305

difference in PTSD symptoms was identified on self-­reported symptoms but

not on clinician-­rated symptoms (Oehen et al., 2013). Dropout rates were
12.5% and 25% in the 125 mg and active control groups, respectively.
Finally, Mithoefer and colleagues (2018) randomized 24 mostly male
service personnel (firefighters, police officers, and veterans) with PTSD to
MDMA-­assisted psychotherapy with three mediation doses: 125 mg (n = 12),
75 mg (n = 7), and active placebo 30 mg MDMA (n = 7) plus a 50% supple-
mental dose after 2 hours in all conditions. The 75 mg and 125 mg demon-
strated significantly greater reduction in PTSD symptoms compared to the
30 mg group (1 month after the second experimental session between-­g roup
d = 1.1 for 125 mg vs. active placebo; d = 2.8 for 75 mg vs. active placebo). As
in the previous Mithoefer study, there was adequate random sequence gen-
eration, allocation concealment, and blinding of outcome assessors, and the
use of an active placebo dose also ensured adequate blinding of participants
and personnel.
While recent meta-­analytical findings (Hoskins et al., 2020) demon-
strate impressive effects for this novel drug-­assisted therapy (kappa = 3,
n = 58, SMD = –1.31 [–1.92, –0.69]), effects for MDMA-AP are difficult to
interpret given the sparse literature and methodological issues, including
inability to maintain participants blind to the study drug, where an inactive
placebo was used, and the use of a novel psychotherapy approach that has
not been compared to conventional trauma-­focused psychological therapies
without drug augmentation. There are currently several ongoing Phase II
studies in the United States, Canada, and Israel, with more open-label fea-
sibility studies planned across Europe. In the United States, the Food and
Drug Administration has granted a Breakthrough Therapy Designation for
MDMA-AP, with Phase III studies commencing soon. Future research will
benefit from follow-­up studies replicating and extending this work in addi-
tional research groups and comparisons with empirically supported psycho-
therapies.

Other Novel Augmentation Agents

Additional agents that show promise for augmenting PE include methylene-­
blue and yohimbine. In a sample of 42 patients with chronic PTSD, methylene-­
blue plus imaginal exposure resulted in more treatment responders (number
needed to treat = 7.5) and a higher reported quality of life (3-month follow-
­up between-­g roup d = 0.58) compared to placebo plus imaginal exposure
(Zoellner et al., 2017). In a sample of 26 males with combat-­related PTSD,
yohimbine plus PE was associated with higher objective arousal, indicated
by increased heart rate and blood pressure, and subjective arousal, indicated
by increased subjective report of distress, during the combined drug and
exposure session. Those who received yohimbine showed lower trauma-­cued
heart rate reactivity during a script-­driven imagery task 1 week following
this session (between-­g roup difference in heart rate = 3.15 beats per minute,
d = 0.25; Tuerk et al., 2018). Notably, yohimbine was associated with greater
306 Treatments for Adults

between-­ session habituation (d = 0.32) and more rapid improvement in

depression (d = 0.21) but not PTSD symptoms over the course of treatment.
One recent study examined the effect of propranolol provided 90 min-
utes before brief (15–25 minutes) memory reactivation sessions for 60 adults
diagnosed with PTSD (Brunet et al., 2018). Participants received 0.67 mg/
kg of short-­acting propranolol, plus 1.0 mg/kg of long-­lasting propranolol
90 minutes prior to six weekly sessions, during which participants read their
trauma narrative out loud. This study was designed to target reconsolidation
of trauma memories specifically. Those randomized to receive propranolol
(n = 30) reported significantly lower PTSD symptom severity from clinical
interview compared to those who received placebo (n = 31) after six sessions
(within-­g roup d = 1.76 and d = 1.25, respectively).
Corticosteroids have also been investigated as augmentation agents for
PE with mixed results. Dexamethasone (0.5 mg) or placebo was adminis-
tered the night before VRE in 27 post-9/11 veterans (n = 13 and n = 14,
respectively; Maples-­Keller et al., 2019). The dropout rate was significantly
higher in the dexamethasone + VRE group (76.9%) compared to the placebo
+ VRE group (28.5%). Results suggested that the dexamethasone group may
have experienced an increase in reexperiencing symptoms at Session 2 fol-
lowing drug administration. In contrast, hydrocortisone administered 20
minutes prior to imaginal exposure sessions in a sample of veterans receiv-
ing PTSD treatment (PE) resulted in greater retention in treatment and sub-
sequently greater reductions in PTSD severity compared to placebo (Yehuda
et al., 2015).
One additional augmentation strategy of recent interest combines
repetitive transcranial magnetic stimulation (rTMS) with trauma-­focused
treatment. In one study, this approach involved rTMS right over dorsolateral
prefrontal cortex compared to sham just prior to weekly cognitive process-
ing therapy (CPT) sessions. One hundred three Iraq and Afghanistan vet-
erans with combat-­related PTSD were randomized to receive either rTMS +
CPT (n = 54) or Sham + CTP (n = 49). Results showing that the rTMS + CPT
group demonstrated greater symptom reduction across both clinician-­rated
and self-­reported PTSD symptoms (Session 5 through 6-month follow-­up
between-­g roup d ≥ 0.79; Kozel et al., 2018). Future work should investigate
mechanisms of this effect as well as optimal timing and dose.

Practical Delivery of Combined

Efficacious Monotherapies

As a general clinical strategy, combination treatment of PTSD has not

been well studied. In line with recent clinical recommendations (American
Psychological Association, 2017; U.S. Department of Veterans Affairs &
Department of Defense, 2017), patients should be offered evidence-­based,
trauma-­focused therapy first. If a patient declines therapy or is unable to
Combined Psychotherapy and Medication Treatment 307

participate, medications should be recommended based on several clinical

considerations, including patient preference, symptom profile, comorbid
diagnosis, and the medication’s side effects (Ehlers, Chapter 15, this vol-
ume). For patients who have not fully responded to medication alone, the
addition of exposure therapy, like PE, may be indicated, in line with findings
from Rothbaum and colleagues (2006). However, findings from Simon and
colleagues (2008) suggest that nonreponse to exposure therapy does not
warrant the addition of medication, at least not the addition of an SSRI after
nonresponse to PE. Furthermore, a clear benefit for starting evidence-­based
psychotherapy and pharmacotherapy simultaneously at the start of treat-
ment has not been found in the literature, with multiple studies showing no
added benefit of combinatin therapy over PE alone for PTSD (Popiel et al.,
2015; Rauch et al., 2019) or benefits that were not sustained (Schneir et al.,
2012). There is a lack of research examining evidence-­based psychothera-
pies other than exposure therapy in combination with medication for the
treatment of PTSD. However, there is no reason to expect findings would be
different for these other evidence-­based approaches. Taken together, these
studies suggest that SSRIs do not boost the effects of PE whether adminis-
tered after nonresponse or throughout therapy. Thus, providers may need
to temper expectations regarding combination approaches and look at
alternative strategies to make “course corrections” after nonresponse to PE,
especially if PE session frequency is low. Maintaining weekly or more fre-
quent PE sessions without adding an SSRI may be a more effective approach.
The finding of added benefits from the addition of PE after nonresponse
to an SSRI is encouraging given that patients are more likely to present
after nonresponse to SSRI monotherapy due to greater access to this treat-
ment compared to evidence-­based psychotherapy. Although these studies
are informative, research on combining evidence-­based pharmacotherapy
and psychotherapy is limited. Novel methods are needed to identify addi-
tional factors that could inform the prescription of combination therapy. For
example, it may be the case that adding an SSRI to PE is beneficial, but only
for those with certain preferences or diagnostic profiles. Studies to date have
not been able to tease apart these potential prescriptive predictors. Until
clear benefits for combination therapy can be identified for specific popula-
tions of patients, this approach should not be recommended, consistent with
published guidelines.

Practical Delivery of Augmentation Strategies

The literature on psychotherapy-­specific augmentation of exposure-­based

PTSD treatment is young, making strong practical clinical recommendations
premature. However, the studies outlined in this chapter can inform recom-
mendations for future research. It is theorized that augmentation strate-
gies for exposure-­based treatments work by enhancing extinction learning
308 Treatments for Adults

and consolidation processes both during and after exposure sessions (see
Singewald, Schmuckermair, Whittle, Holmes, & Ressler, 2015), suggesting a
window of optimal combination effect that will be different depending on
medication type. Thus, the timing of medication is a critical clinical issue.
For DCS, timing of dose may explain mixed findings in the literature.
In a general review of DCS augmentation across diagnoses, Hofmann (2014)
highlighted that studies finding a positive effect for this augmentation
strategy administer smaller doses of DCS (50–250 mg) earlier before (1–2
hours) less frequent exposure sessions (three to five). Moreover, this review
suggested that positive effects for DCS may only occur when the exposure
therapy is successful and that for nonsuccessful exposures, DCS may lead
to negative effects (e.g., Litz et al., 2012). In a more recent review and meta-­
analysis of DCS across anxiety disorders, the optimal dosing was found to be
50 mg, administered at least 60 minutes prior to nine sessions of exposure
therapy (Rosenfield et al., 2019). For PTSD, mixed results may be related to
dosing, timing, and therapy factors. Or, it may be the case that DCS is not a
beneficial augmentation strategy. Without stronger evidence supporting the
augmentation benefits of DCS, clinical recommendations for its use cannot
be developed.
For MDMA, the long duration and nature of the drug’s effect impact the
type of psychotherapy that can be administered. The only studies of MDMA
for the treatment of PTSD tested a novel treatment designed specifically
for MDMA-­assisted therapy. This intervention involves two or three drug-­
assisted psychotherapy sessions of 6–8 hour duration, which are relatively
unstructured. The participant is invited to focus their attention inward, use
eye shades and music, and a 50% supplemental dose is offered after 2 hours
to prolong the peak experience. Given the novel psychotherapy design, it is
not possible to determine the efficacy of MDMA as an adjunct to evidence-­
based treatment for PTSD. More research is needed to determine whether
MDMA-­assisted psychotherapy is an effective, stand-alone treatment or if
MDMA can augment evidence-­based psychotherapy.

Future Developments

The literature for combination treatments for PTSD is underdeveloped.

Studies replicating previous findings and identifying mechanisms of change
are needed to provide strong clinical recommendations for or against
combination approaches. Novel research methods will be needed to iden-
tify whether any subpopulations may benefit from a certain combination
approach to develop more precise and specialized clinical care for PTSD.
Studies of daily-dosed medications should broaden their scope to examine
other SSRIs and evidence-­based psychotherapies and examine timing of
the start-of-­medication dose in a more systematic way. For example, a trial
comparing different starting points for adding SSRIs to treatment within
Combined Psychotherapy and Medication Treatment 309

the same sample may be better able to identify not only the optimal timing
for intervening with a combination approach, but also more precise indica-
tors of who is less likely to respond and more amenable to a combination
approach.
Alternatively, acute-­
acting augmentation agents to enhance specific
components of psychotherapy demonstrate either consistently mixed find-
ings in the literature (e.g., DCS) or are currently lacking in systematic study
(e.g., yohimbine or propranolol). Because each augmentation agent is the-
orized to interact with different potential mechanisms of psychotherapy
response (e.g., emotional engagement, cognitive rigidity, cortisol regula-
tion), specific experimental designs are needed to understand these effects.
For example, the theory that propranolol impacts memory consolidation has
led researchers to study augmentation with a memory consolidation para-
digm, which has specific implications for trauma-­memory-­focused interven-
tions, like PE. Compared to other augmentation agents, DCS has the larg-
est literature base examining its use in the treatment of PTSD. The mixed
findings suggest that timing and dosage are important to efficacy for this
approach. However, while future research may clarify these moderating fac-
tors, it may also be the case that DCS is not as strong a therapeutic enhancer
as originally theorized, especially in heterogeneous PTSD patients. Given
the large number of novel theorized augmentation agents, it is inevitable
that agents will be found to not have an effect or possibly have a negative
effect on psychotherapy. It is critical for future research to interpret and
report these null findings to identify reliable and clinically meaningful aug-
mentation strategies.
MDMA-­assisted psychotherapy has demonstrated efficacy as a treatment
for PTSD in three small clinical trials. Due to the unique psychotherapy
delivered in these studies, it is difficult to determine the efficacy of MDMA
as an augmentation strategy for evidence-­based treatment for PTSD. Like
other augmentation agents, MDMA has been studied in animal models that
suggest specific mechanisms of change related to extinction learning (Young
et al., 2017). Future studies are needed to determine whether MDMA is a fea-
sible and effective augmentation agent for evidence-­based psychotherapies.
As psychedelics like MDMA and psilocybin gain prominence in the clinical
literature as potential therapy-­assisted interventions (see Mithoefer, Grob,
& Brewerton, 2016), research will be needed to specify the type of therapy
that should be provided with these medications as well as their safety and
efficacy for treating PTSD.
Finally, future research should determine which medication and psy-
chotherapy combinations are most effective, why they are effective, and for
whom. Mechanisms of change in combination approaches have yet to be
identified. Patient factors are likely to play a role, including preference for
medication versus psychotherapy. A recently published study doubly ran-
domized individuals to choose or be randomized to receive either sertra-
line or PE as monotherapies (Zoellner, Roy-Byrne, Mavissakalian, & Feeny,
310 Treatments for Adults

2018). Findings indicated that being able to choose one’s preferred treat-
ment resulted in larger gains, regardless of the treatment received. Future
research should test whether preference impacts combination treatment out-
come.

Summary

Combination approaches for the treatment of PTSD have the potential to

enhance treatment efficacy and improve response rates. The literature for
augmenting exposure therapy with SSRIs is still underdeveloped, and com-
bination strategies were not considered by the ISTSS Posttraumatic Stress
Disorder Prevention and Treatment Guidelines and are not recommended by
other recent PTSD treatment guidelines (American Psychological Associa-
tion, 2017; U.S. Department of Veterans Affairs & Department of Defense,
2017). Combination approaches with medications like SSRIs are commonly
practiced in clinical settings and warrant further study to determine best
practices. Several novel augmentation agents designed to enhance psycho-
therapy for PTSD, such as DCS, methylene blue, dexamethasone, hydrocor-
tisone, yohimbine, propranolol, MDMA, and rTMS, are being examined in
clinical populations with the potential to impact future clinical recommen-
dations and improve treatment for PTSD. Future research should focus on
testing these and other potential augmentation strategies in novel experi-
mental designs that can identify not only whether these agents convey addi-
tive benefits, but also who is most likely to benefit from them and what is the
most optimal administration strategy.

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C H A P TE R 18

E‑Mental Health
Catrin Lewis and Miranda Olff

D espite robust evidence to indicate the best strategies for the assessment
and treatment of posttraumatic stress disorder (PTSD) as reflected across
the chapters of this volume, many factors limit the availability and uptake of
these interventions. These logistical issues include the cost of interventions
(National Institute for Health and Care Excellence, 2018); the perceived
stigma associated with accessing support (Cuijpers, van Straten, & Ander-
sson, 2008); and geographical variations in service provision (Griffiths &
Christensen, 2007). In response, there has been a growing interest in elec-
tronic mental health (e-­mental health) as an option for increasing access to
appropriate care (Olff, 2015).

What Is E‑Mental Health?

E-­mental health has been defined as “mental health services and informa-
tion delivered or enhanced through the Internet and related technologies”
(Christensen, Griffiths, & Evans, 2002). It is a generic term that encompasses
the use of digital technologies for screening and diagnosis, health promo-
tion, prevention, monitoring, early intervention, treatment, or relapse pre-
vention, as well as for improvement of health care delivery and professional
development (Riper et al., 2010). It is a broader concept than tele-­health or
tele-­medicine, which use technology to connect health care professionals
with consumers for real-time delivery of standard care (Ashwick, Turgoose,
& Murphy, 2019; Sood et al., 2007).
E-­mental health may also be termed “computerized,” “Internet-­based,”
“Web-based,” or “online” mental health. Various e-­mental health applica-
tions have been developed, including information pages and portals; online
support forums and social networks; blogs and podcasts; training modules

314
E‑Mental Health 315

for providers; and tools for assessment or diagnosis. Exciting developments

also include virtual reality, which integrates real-time computer graph-
ics with other sensory input devices to immerse a participant in a virtual
environment and facilitate the processing of memories associated with the
traumatic event (Rizzo, Reger, Gahm, Difede, & Rothbaum, 2009; Roth-
baum, Hodges, Ready, Graap, & Alarcon, 2001). However, for the purpose
of this chapter, we focus on the role of structured Internet-­based therapeutic
interventions that have been developed for the prevention and treatment of
PTSD in adults, while acknowledging that e-­mental health serves a broader
function in the mental health sector and that rapid progress is being made
in the field of online assessments (Price et al., 2018; van der Meer, Bakker,
Schrieken, Hoofwijk, & Olff, 2017).

E‑Mental Health Interventions

for the Prevention of PTSD

There is little evidence to support the provision of preventative interventions

to mitigate the psychological impact of trauma exposure (see O’Donnell,
Pacella, Bryant, Olff, & Forbes, Chapter 8, this volume). It follows that rela-
tively few attempts have been made to develop and evaluate Internet-­based
interventions for the prevention of PTSD (Ennis, Sijercic, & Monson, 2018).
Here, we will summarize the preventative e-­mental health interventions that
have been developed to date.

Trauma TIPS
Developed in the Netherlands, Trauma TIPS is a self-­g uided intervention
aimed at the prevention of PTSD in injury patients (Mouthaan, Sijbrandi,
de Vries, et al., 2013; Mouthaan, Sijbrandij, Reitsma, Gersons, & Olff, 2011;
Mouthaan, Sijbrandij, Reitsma, Luitse, et al., 2011). Based on cognitive-­
behavioral principles, Trauma TIPS incorporates psychoeducation, stress
management, and in vivo exposure. It consists of six steps, including an
introduction; video clips of a clinician and three patient stories; text describ-
ing common physical and psychological reactions after trauma; audio clips
with instructions for stress management techniques; contact information for
assistance/additional support for enduring symptoms; and a Web forum for
peer support. The total duration of the program is approximately 30 min-
utes.

Afterdeployment.org
Afterdeployment.org and its accompanying app, LifeArmor, provide Inter-
net-based self-­assessment, self-­management strategies, videos, and materials
that address a number of topics in addition to PTSD, such as injury, alcohol
316 Treatments for Adults

and drug use, sleep, anger, military sexual abuse, and resilience after trauma
exposure (Bush, Bosmajian, Fairall, McCann, & Ciulla, 2011). It is primar-
ily intended as an adjunct to face-to-face therapy (Ruzek et al., 2011). It was
designed to be used by health care professionals, military personnel, and
their families. It includes psychoeducation as well as self-­assessment tools
and interactive content.

My Disaster Recovery
Although not specifically targeting PTSD, another Internet-­based interven-
tion designed for use in the aftermath of trauma, My Disaster Recovery,
provides advice on seeking professional help, relaxation, social support,
unhelpful ways of coping, self-talk, and trauma triggers and memories
(Benight, Ruzek, & Waldrep, 2008). It consists of six interactive modules,
which include self-tests and video vignettes.

Cancer Coping Online

Cancer Coping Online is another self-­ g uided Internet-­
based program
grounded in cognitive-­behavioral principles (Beatty, Koczwara, & Wade,
2011). The six-­session program focuses on teaching coping strategies for
reducing cancer-­specific traumatic-­stress symptoms, depression, and anxiety.

RealConsent
Another approach is to develop interventions aimed at the prevention of
trauma. RealConsent is an Internet-­based bystander approach to the pre-
vention of sexual violence (Salazar, Vivolo-­K antor, Hardin, & Berkowitz,
2014). It is based on social cognitive theory, social norms theory, and the
bystander educational model, with the aims of increasing prosocial inter-
vening behaviors and preventing sexually violent behavior toward women.
The intervention consists of six 30-minute modules including interactivity,
didactic activities, and episodes of a serial drama illustrating positive and
negative behavior.

E‑Mental Health Interventions

for the Treatment of PTSD

E-­mental health is said to be one of the most promising opportunities for

more timely and effective treatment of common mental health problems
(Christensen & Hickie, 2010). Internet-­based psychological therapies have
been developed and implemented for a range of disorders, with the aim of
reducing health care expenditures and broadening access to psychological
therapies. Since the emergence of the first e-­mental health interventions
E‑Mental Health 317

for the treatment of mental disorders, a number of systematic reviews have

supported their efficacy for depression (Spek et al., 2007), anxiety disorders
(Lewis, Pearce, & Bisson, 2012; Olthuis, Watt, Bailey, Hayden, & Stewart,
2015), and eating disorders (Schlegl, Bürger, Schmidt, Herbst, & Voderhol-
zer, 2015).
Internet-­based interventions for the treatment of a mental disorder
are highly structured online programs that aim to improve users’ mental
health by enhancing their knowledge and skills (Barak, Klein, & Proudfoot,
2009). These programs are commonly based on cognitive-­behavioral ther-
apy (CBT), but sometimes include components of other established psycho-
logical treatments, such as acceptance and commitment therapy (ACT) and
mindfulness. The content of existing therapies is not usually altered, deviat-
ing from traditional psychological treatment only in terms of the method of
delivery (Cuijpers, Donker, van Straten, Li, & Andersson, 2010).
Internet-­based interventions vary in terms of the level of therapist assis-
tance provided. They can be delivered with regular assistance from a highly
engaged specialist therapist who provides input and feedback on homework,
encourages engagement with the program, and provides technical assis-
tance with the platform. They can also be delivered by a nonspecialist men-
tal health professional who briefly introduces the program and intervenes
to check on progress or provides input on demand, often by telephone or
by e-mail. Finally, they can adopt a stand-alone approach, in which no thera-
pist assistance is provided. There is evidence to support the superiority of
interventions that include input from a therapist (Lewis et al., 2012; Lewis,
Roberts, Bethell, Robertson, & Bisson, 2018; Spek et al., 2007).
The development and evaluation of e-­mental health interventions for
PTSD have lagged behind other disorders. The first RCT of a self-help-­based
intervention for PTSD preceded e-­mental health (Ehlers et al., 2003). This
intervention was found to be no more efficacious than repeated assessments;
however, the self-help materials may not have been optimal and no therapist
support or follow-­up appointments were provided. This finding, however,
may have discouraged the development of further interventions for a time.
It is also likely that the potential for symptom worsening and adverse events
has discouraged the development and implementation of interventions his-
torically.
We know that psychological therapies are effective interventions for
PTSD, and there is a substantial body of evidence in support of CBT-based
treatment (see, in this volume, Chard, Kaysen, Galovski, Nixon, & Mon-
son, Chapter 13; Ehlers, Chapter 15; Riggs, Tate, Chrestman, & Foa, Chap-
ter 12). CBT protocols are structured, thereby lending themselves well to
Internet-­based delivery. Due to a combination of these factors, the majority
of Internet-­based interventions for the treatment of PTSD have been CBT-
based.
Most Internet-­based interventions for PTSD initiate treatment with psy-
choeducation and the rationale for CBT-based treatment (Improving Access
318 Treatments for Adults

to Psychological Therapies, 2010). These programs incorporate cognitive

techniques, with the aim of identifying and modifying unhelpful patterns
of cognition (Newman, Erickson, Przeworski, & Dzus, 2003). Usually, behav-
ioral components are included; they generally encompass imaginal and in
vivo exposure (Lewis et al., 2017). Trauma-­focused programs involve activat-
ing the trauma memory, usually by writing about the traumatic event. Most
conclude with a section on relapse prevention that focuses on staying well,
recognizing signs of relapse, and offering advice on what to do if problems
recur (Gega, Marks, & Mataix-­Cols, 2004). There is a distinction between
Internet-­CBT and online psychoeducation. Although the two overlap in con-
tent, psychoeducation aims to increase knowledge, whereas Internet-­CBT
aims to teach skills and techniques that can be used to overcome specific
PTSD symptoms. Internet-­CBT programs are often based on existing face-
to-face psychotherapy protocols and share many common features (Anders-
son & Cuijpers, 2009).
A number of e-­mental health interventions have been developed for the
treatment of PTSD. They are outlined here, followed by the findings with
regard to efficacy in the next section (see Figure 18.1).

Interapy
The first formally evaluated e-­mental health intervention to treat PTSD was
developed in the Netherlands. Known as Interapy, it involves 10, 45-min-
ute writing assignments completed over a period of 5 weeks. The interven-
tion consists of three treatment phases: (1) self-­confrontation, (2) cognitive
reappraisal, and (3) social sharing. Initially, psychoeducation is presented in
relation to the mechanisms of exposure. At the beginning of each writing
phase, individuals plan when they are going to write. Halfway through and
at the end of each treatment phase, the person with PTSD receives feed-
back and further writing instructions from his or her therapist via e-mail,
which is based on a treatment manual that tailors feedback to specific needs.
The e-mail feedback includes recognition and reinforcement of the person’s
work and motivation. In the first writing phase, the therapist helps the per-
son with PTSD to write about the traumatic event, with a focus on his or

• Interapy
• PTSD Coach
• Spring
• Survivor to Thriver
• DElivery of Self-TRaining and Education
for Stressful Situations (DESTRESS)

FIGURE 18.1. E-­mental health interventions for the treatment of PTSD.

E‑Mental Health 319

her most painful images and thoughts, in the first person and in the pres-
ent tense, including sensory details. If necessary, the therapist supports the
individual to address any avoided aspects of the trauma. During the second
phase, psychoeducation in relation to the principles of cognitive change is
presented. The aim is to form a new perspective on the traumatic event and
to regain a sense of control. This involves writing a supportive letter to an
imaginary friend who has been through the same experience, reflecting on
the friend’s feelings of guilt and shame and unrealistic thoughts. During the
third phase, individuals receive psychoeducation about the positive effects
of social sharing. In a final letter, the person with PTSD summarizes what
happened, reflects on the therapeutic process, and describes how he or she
plans to cope now and in the future. Warriors Internet Recovery and Edu-
cation (WIRED) is a version of Interapy that has been adapted for use with
veterans (Krupnick et al., 2017).

PTSD Coach
One of the most well-known e-­mental health interventions for PTSD is PTSD
Coach, developed jointly by the U.S. Department of Veterans Affairs (VA)
and Department of Defense (DoD; Kuhn et al., 2014). PTSD Coach is a psy-
choeducational and self-­management tool for acute distress related to PTSD
(Kuhn et al., 2018). It targets military veterans as well as the broader civilian
population. It consists of four core sections. The “Learn” section provides
PTSD psychoeducation, information about professional support, and mate-
rial related to PTSD and the family. The “Track Symptoms” feature allows
users to complete the PTSD Checklist for the fifth edition of the Diagnostic
and Statistical Manual of Mental Disorders (DSM-5; Blevins, Weathers, Davis,
Witte, & Domino, 2015) and to receive feedback on their severity scores, with
recommendations for treatment if indicated. This section also offers track-
ing of symptoms over time with the option of reminders and the ability to
view a graph of changes in symptoms over time. The “Manage Symptoms”
section offers the user the opportunity to learn coping tools that target dif-
ferent types of PTSD symptoms. The “Get Support” section contains crisis
support resources, including supportive contacts added by the user. PTSD
Coach is available free of charge from the iTunes and Google Play app stores
for use with Apple and Android devices (Kuhn et al., 2014). The app has
been translated and adapted into several languages, for example, Swedish
(Cernvall, Sveen, Bergh Johannesson, & Arnberg, 2018). The slightly more
generic Dutch version, called Support Coach, is now also available in app
stores (van der Meer, Bakker, van Zuiden, Lok, & Olff, 2020).

Spring
Spring is a CBT-based program developed in the United Kingdom (Lewis,
Roberts, Vick, & Bisson, 2013). It was systematically developed following
320 Treatments for Adults

Medical Research Council (MRC; 2000) guidance for the development of

a complex intervention. The work followed an iterative process incorporat-
ing qualitative work to model the intervention, followed by two pilot studies
to refine it on the basis of quantitative and qualitative outcomes (Lewis et
al., 2013). Collaboration with a software development company produced
an interactive online version of the program. It includes eight online steps
designed for delivery over 8 weeks. The eight steps are designed to be com-
pleted sequentially, with later steps relying on mastery of techniques taught in
earlier steps. The program draws on active ingredients from trauma-­focused
CBT. Each of the eight steps activates a new tool or technique derived from
CBT, which aims to reduce traumatic stress symptoms. The program is initi-
ated with an hour-long appointment with a therapist, followed by fortnightly
30-minute sessions with a therapist. The aim of the guidance is to offer con-
tinued support, monitoring, motivation, and assistance with problem solv-
ing.

Survivor to Thriver
Survivor to Thriver was developed in the United States (Littleton, Grills,
Kline, Schoemann, & Dodd, 2016). The intervention consists of nine mod-
ules. The first modules focus on psychoeducation, relaxation, grounding,
and adaptive coping. The next modules introduce cognitive interventions.
The final modules focus on using cognitive techniques to address specific
concerns relevant to rape victims (e.g., self-blame, safety concerns). Modules
are completed one at a time, and access to each subsequent module is granted
by the therapist. Each module contains a video clip discussing the topic cov-
ered in the module, a written description of the skills or techniques being
introduced, and written examples of women modeling the skills. The pro-
gram also includes interactive exercises designed to help women think about
the extent to which the particular issue raised in the module is a concern for
them or to practice a described skill or technique and receive feedback on
their practice. The interactive exercises provide information to enable the cli-
nician to determine how long a client should spend on a particular module.

DElivery of Self‑TRaining and Education

for Stressful Situations (DESTRESS)
Also developed in the United States, DESTRESS-­PC is a non-­trauma-­focused
variant of CBT and stress inoculation training (Litz et al., 2007) designed for
symptoms resulting from military trauma. The website allows access to psy-
choeducation about PTSD, stress, and trauma, as well as common comorbid
problems and symptoms such as depression and survivor guilt. It also pro-
vides strategies for the management of stress, anger, and sleep disturbance.
In addition, it teaches cognitive change techniques and strategies to alter self-
talk. Individuals are asked to generate a hierarchy of avoided situations that
E‑Mental Health 321

trigger deployment memories. Each interaction with the website is intended

to take 15–30 minutes, with related homework assignments taking another
half hour. Clinicians are able to access a section of the DESTRESS website to
monitor compliance and symptoms, and provide guidance as needed.

Advantages of E‑Mental Health

Over the past decades, the Internet has altered most aspects of our day-
to-day lives dramatically. It has become a basic tool for the dissemination
of information, entertainment, communication, education, and knowledge
transfer. Digital technologies have multifaceted attributes that lend them-
selves intrinsically to the delivery of mental health care. These attributes give
rise to the numerous advantages of e-­mental health, which are considered
here (see Figure 18.2).

Timely Intervention
There is an inevitable delay between the onset of a mental disorder and the
start of evidence-­based psychotherapy (EBP) (Wang et al., 2007). Although
some individuals are motivated and able to access timely intervention, the
interval between symptoms arising and receipt of appropriate treatment
varies substantially, and disorders including PTSD often go untreated for
many years (Wang et al., 2005). If left untreated, PTSD is associated with
functional and emotional impairment (Amaya-­Jackson et al., 1999; Cloitre,
Miranda, Stovall-­McClough, & Han, 2005), reduced quality of life (Olatunji,
Cisler, & Tolin, 2007; Zatzick et al., 2014), a predisposition for the develop-
ment of other psychiatric and physical illnesses (Brady, Killeen, Brewerton,
& Lucerini, 2000; Pacella, Hruska, & Delahanty, 2013), increased suicidal
ideation (Krysinska & Lester, 2010), higher health care utilization (Domin
Chan, Cheadle, Reiber, Unützer, & Chaney, 2009), and higher rates of
alcohol abuse and dependence (Breslau, Davis, & Schultz, 2003; Jacobsen,

• Timely intervention
• Improved accessibility
• Anonymity
• Flexibility
• Standardization
• Empowerment
• Acceptability
• Potential for cost-effectiveness

FIGURE 18.2. Advantages of e-­mental health.

322 Treatments for Adults

Southwick, & Kosten, 2001). E-­mental health may remove some of the bar-
riers to EBP and allow earlier intervention, potentially preventing further
sequelae of untreated PTSD.

Improved Accessibility
A distinct advantage of e-­mental health is that it allows individuals living
in geographically remote areas to access mental health care resources they
might not otherwise be able to access (Griffiths & Christensen, 2007). There
is evidence that individuals living in rural areas have a similar prevalence
of mental health problems to those living in urban areas (Caldwell, Jorm, &
Dear, 2004); however, fewer people in rural areas access services (Roberts,
Battaglia, & Epstein, 1999). E-­mental health interventions have the scope to
reach users spread over a broader geographical area than traditional mental
health services (Christensen & Hickie, 2010), breaking down barriers and
supporting greater equity of care. E-­mental health also offers a potentially
crucial method of delivering mental health interventions to those exposed
to war, ethnic conflict, and natural disasters on the basis that entire com-
munities are often traumatized and may be difficult to access (Ruzek, Kuhn,
Jaworski, Owen, & Ramsey, 2016).

Anonymity
E-­mental health enables anonymous or discreet access to support and treat-
ment for those who might not otherwise seek help (Williams, 2001). It enables
access to mental health resources without visiting a health care professional.
Because stigma creates a culture of secrecy and denial around mental health
that impedes engagement with mental health services (Corrigan, Druss, &
Perlick, 2014), this is a distinct advantage of the approach.

Flexibility
E-­mental health resources are accessible 24 hours a day, allowing individu-
als to work through materials in their own time and at their own pace. For
those accessing treatment online, it enables them to fit this in around other
commitments (Williams & Whitfield, 2001). This may be especially advan-
tageous to individuals who are employed, have family demands, or lead
otherwise busy lives. It also negates or reduces the need to arrange child
care to attend therapy sessions. E-­mental health interventions enable access
to treatment from home, which has several potential benefits (Carlbring,
Westling, Ljungstrand, Ekselius, & Andersson, 2001). This flexibility may
be appealing to individuals who experience difficulties concentrating or
focusing on tasks. Furthermore, individuals may feel more comfortable and
able to address their feelings at home, on their own, than in the presence
E‑Mental Health 323

of a therapist (Suler, 2004). Engaging in treatment at home is also useful

to those who suffer mobility problems or difficulties leaving the house for
psychological reasons (Lina, Isaac, & David, 2004). The opposite is also true,
and at-home treatment may support an avoidance of leaving the house, or a
tendency for individuals to avoid engaging with e-­mental health materials.

Standardization
E-­mental health services can be delivered with a high degree of fidelity
(Christensen et al., 2002). The content of e-­mental health programs is usu-
ally delivered to all users in broadly the same way. There is less reliance on
therapist skill and less scope for clinicians to deviate from the treatment
protocol if the intervention is guided. This may also act as a disadvantage.
For more prescriptive and delineated intervention manuals, there may be
less opportunity for tailoring interventions to the individual and his or her
specific needs.

Empowerment
E-­mental health supports a cultural shift in mental health services, giving
consumers greater choice and the opportunity for input into care for their
condition. E-­mental health enables individuals to take more of an active
role in addressing their illness and to claim responsibility for their recovery.
Guided interventions create a therapeutic relationship based on collabora-
tion consistent with policy focusing on increased involvement of consum-
ers in all aspects of service delivery (Christensen & Petrie, 2013). E-­mental
health has been associated with empowerment, self-­ determination, self-­
control, confidence, and the development of personal coping strategies in
effective recovery (Jacobson & Greenley, 2001). It introduces an approach
whereby individuals work with their clinician to solve problems, drawing
on their own expertise and experience. Although the approach allows an
individual to attribute improvement to his or her own personal efforts, it is
worth noting that the opposite is also true. There may be a tendency for lack
of progress to be viewed as a personal failing (Fairburn, 1997).

Acceptability
There is public enthusiasm for psychological therapy, with it often favored
over medication by individuals seeking treatment for a mental disorder.
E-­mental health offers a way to fulfill the demand for such therapies through
an approach that has been found to be acceptable to users (Botella et al.,
2009). There is also capacity for the development of bespoke resources to
suit the needs of particular subgroups (e.g., military veterans, rape survi-
vors), which may further enhance the acceptability of e-­mental health.
324 Treatments for Adults

Potential for Cost‑Effectiveness

Scarcity of financial resources is a powerful rationale for the exploration of
innovative alternatives for mental health care (Donker et al., 2015). Embrac-
ing the opportunities offered by e-­mental health has the potential to allevi-
ate some of the resource challenges faced by the mental health sector. From
an economic perspective, e-­ mental health requires fewer personnel and
less infrastructure, offering a potentially lower-cost alternative to standard
mental health services (Hedman et al., 2014). E-­mental health interventions
aimed at the treatment of PTSD place less demand on therapist time, a costly
and limited resource. Using the Internet to deliver EBP has the capacity to
reduce the cost of effectively delivering EBP (Hedman et al., 2011; Hedman,
Ljotsson, & Lindefors, 2012). However, the economic evaluation of e-­mental
health has not received sufficient attention (Donker et al., 2015), and further
work is required before e-­mental health interventions can be recommended
not simply based on an assumption of cost-­effectiveness.

Limitations of E‑Mental Health

Ongoing work seeks to understand the role that e-­mental health potentially
has to play in the mental health sector. It is worth acknowledging the limita-
tions of the delivery method and discussing the challenges that surround
implementation of the approach (see Figure 18.3).

Ethical and Legal Responsibility

There is some resistance to e-­mental health for fear of unethical practice
or legal liability. Concern exists that information may be misinterpreted or
used incorrectly (Christensen et al., 2002). The quality of information on
websites is highly variable. It can be difficult for consumers to ascertain if
a source is legitimate, or if information is reliable. Data security consider-
ations are of importance and often overlooked or underestimated (Bennett,
Bennett, & Griffiths, 2010).

• Ethical and legal responsibility

• Oversimplification
• Difficulties using materials
• Lack of evidence supporting acceptability
to diverse groups

FIGURE 18.3. Limitations of e-­mental health.

E‑Mental Health 325

Oversimplification
Critics of the approach have suggested that e-­mental health oversimplifies
mental disorders and offers unsophisticated short-term solutions to diffi-
cult and complex issues. Others have commented that treatment delivered
via e-­mental health creates unrealistic expectations and the potential for
individuals to feel as though they have failed when desired results are not
attained. There is also the possibility for e-­mental health to cause harm
through improper use or misunderstanding. Others suggest the danger of
self-help interventions being relied upon at times of crisis, in place of the
individual seeking more appropriate support (Taylor & Luce, 2003). These
issues might be avoided through thoughtful planning of e-­mental health
interventions, coupled with guidance for its responsible use.

Difficulties Using Materials

Gaining benefit from e-­mental health resources may be challenging to those
lacking motivation or the ability to concentrate. An inability to engage with
the material may lead to perceived failure with an impact on self-­esteem.
The addition of guidance from a trained facilitator may alleviate this short-
coming to some extent. Materials written to motivate and reassure may also
serve the same purpose when guidance is absent or limited.

Lack of Evidence Supporting Acceptability

to Diverse Groups
When it comes to acceptability, we know little regarding the views of minor-
ity and culturally diverse groups (Richards, 2004). There is particular con-
cern for those whose first language is not the language of the intervention.
Ideally, culturally specific materials should be developed and evaluated in
a range of languages. Cultural differences may exist in terms of optimal
design, wording, and presentation of materials. Reliance on written text can
also serve to exclude individuals who have difficulty reading. Presenting
materials exclusively on the Internet may also raise questions of accessibility
and potential exclusion, especially with regard to older generations.

Efficacy of E‑Mental Health Interventions

for the Prevention of PTSD

It is not possible to pool the available RCT data on preventative e-­mental

health approaches due to the small number of studies, which often adopted
different primary outcome measures. The efficacy of existing interventions
will be summarized narratively.
326 Treatments for Adults

• Trauma TIPS. The results of the only RCT of Trauma TIPS, which
randomized 300 injury patients to Trauma TIPS or usual care, did not sup-
port its efficacy (Mouthaan et al., 2013). Uptake of the intervention was low,
with only one-fifth of participants logging in. The only significant decrease
in PTSD symptoms occurred among a subgroup of patients with initially
severe traumatic stress symptoms.
• My Disaster Recovery. An RCT of My Disaster Recovery found that
worry was significantly reduced in comparison to an information-­only con-
trol group. A similar, although not significant trend, emerged for depression
(Steinmetz, Benight, Bishop, & James, 2012).
• Cancer Coping Online. Sixty individuals with cancer diagnosed in the
previous 6 months and receiving treatment with curative intent were ran-
domized to Cancer Coping Online or to Internet-­based attention control.
The findings did not support its efficacy in terms of reduction in cancer-­
related PTSD symptoms (Beatty, Koczwara, & Wade, 2016).
• RealConsent. An RCT randomized 743 male undergraduate students
in the United States, ages 18–24, to RealConsent, or a general health promo-
tion program. At 6-month follow-­up, RealConsent participants intervened
more often and engaged in less sexual violence than participants random-
ized to a general health promotion program. However, there was consider-
able attrition and the trial was forced to end prematurely, indicating the
need for caution when interpreting the results.

Summary
Although the Internet provides a useful platform to widely disseminate
preventative approaches, there is insufficient evidence to support the indis-
criminate delivery of preventative e-­mental health interventions to trauma-­
exposed populations. There may, however, be an argument for further explo-
ration of targeted intervention, aimed only at those who are symptomatic
on screening in the aftermath of a trauma. There is also scope for the use
of e-­mental health for widespread, low-cost screening of trauma survivors,
which may serve a useful function in identifying those most likely to benefit.
This, though, remains to be evaluated.

Efficacy of E‑Mental Health in the Treatment

of PTSD

A recent Cochrane review of Internet-­based CBT (i-CBT) for PTSD found 10

RCTs that met eligibility criteria for the review (Lewis et al., 2018). Eight of
the studies compared i-CBT delivered with therapist guidance to a wait-list
control group. Two studies compared guided i-CBT with a non-CBT-based
psychological therapy delivered on the Internet (see Table 18.1).
 TABLE 18.1. Characteristics of Included Studies (Lewis et al., 2018)
Method Method Duration Relevant
of recruit­ of Trauma of treat­ Experimental Control outcome
Country N ment diagnosis type ment intervention Therapist time intervention measures

Engel et al. U.S. 80 Ads Clinician- Military 6–8 wk DElivery of Nurse guidance; Optimized usual PCL;
(2015) rated Self-TRaining monitoring via care (i.e., usual PHQ-8;
and Educa- website; guid- primary care PHQ-15
tion for ance as neces- PTSD treatment
Stressful sary with training of
Situations the clinic provid-
(DESTRESS) ers in manage-
ment of PTSD)

Ivarsson et al. Sweden 62 Ads Clinician- Various 8 wk (unnamed) Clinical psychol- Attention PDS;
(2014) rated ogy students; control (i.e., BDI-II;
guidance once a answering BAI; QOLI
week and occa- weekly questions
sional reminders on well-being,
via website stress, and sleep)

Knaevelsrud, Iraq 159 Ads Self- War 5 wk Interapy Psychotherapists; Wait list PDS;
Brand, Lange, reported related weekly reminder HSCL-25;
Ruwaard, e-mails and EUROHIS-
& Wagner phone contact if QOL
(2015) no response

(continued)

327
328
TABLE 18.1. (continued)
Method Method Duration Relevant
of recruit­ of Trauma of treat­ Experimental Control outcome
Country N ment diagnosis type ment intervention Therapist time intervention measures

Krupnick et U.S. 34 Clinician Self- Military 10 wk Warriors Psychologists; Treatment as PCL-M;

al. (2017) referral reported Internet short response usual PHQ-9
Recovery and after each writ-
Education ing exercise and
(WIRED); as required
adapted from
Interapy

Kuhn et al. U.S. 120 Ads Self- Various 3 mo PTSD Coach None Wait list PCL-C;
(2017) reported PHQ-8

Lewis et al. UK 42 Clinician Clinician- Various 8 wk Spring Trauma thera- Wait list CAPS-5;
(2017) referral rated pists; hour-long BDI; BAI
and ads introductory
session followed
by fortnightly
appointments
face-to-face or by
phone

Littleton et al. U.S. 87 Ads Clinician- Rape 14 wk From Brief check-ins Website includ- PSS-I;
(2016) rated Survivor to by clinical psy- ing psychoeduca- CES-D;
Thriver chology students tion, relaxation, FDAS
 (approximately grounding, and
5 min, approxi- coping strategies
mately once
every 2 wk)

Litz et al. U.S. 45 Ads Clinician- Military 8 wk DElivery of 2-hr-long intro- Non-CBT- PSS-I; BDI;
(2007) rated Self-TRaining ductory sessions based Internet BAI
and Educa- (including basis intervention
tion for assessment); (monitoring
Stressful phone and non-trauma-
Situations e-mail guidance related con-
(DESTRESS) as required cerns, psycho-
education, stress
management);
therapist contact
as required,
focused on non-
trauma-related
concerns

Miner et al. U.S. 49 Ads Self- Various 4 wk PTSD Coach None Wait list PCL-C
(2016) reported

Spence et al. Australia 42 Ads Clinician- Various 8 wk (unnamed) Clinical psy- Wait list PCL-C;
(2011) rated chologist via tele- PHQ-9;
phone, e-mail, GAD-7
and forum

329
330 Treatments for Adults

Eligible studies were randomized controlled trials (RCTs); randomized

cross-over trials; and cluster-­randomized trials of i-CBT for the treatment
of PTSD. Participants were required to be adults aged 16 years or older. At
least 70% of study participants were required to meet full diagnostic criteria
for PTSD according to DSM or ICD criteria, assessed by clinical interview
or a validated self-­report questionnaire. Studies were included regardless of
the type of trauma experienced by the person with PTSD; the severity or
duration of symptoms; or the length of time since trauma. No restrictions
were applied on the basis of comorbidity as long as PTSD was the primary
diagnosis and reduction in traumatic stress symptoms was the main aim
of the intervention. I-CBTs with or without therapist guidance were eligi-
ble, including therapies delivered online and through mobile applications
(apps). Programs that provided up to a maximum of 5 hours of therapist
guidance were included, as well as programs that provided guidance deliv-
ered face-to-face or remotely. There were no restrictions related to the num-
ber of interactions with a therapist or length of the online program. Eligible
comparator interventions were face-to-face psychological therapy; wait list/
minimal attention/repeated assessment/treatment as usual (TAU); and non-
CBT Internet-­delivered psychological therapy. Sample size and publication
status were not used to determine inclusion. Only English-­language studies
were eligible.

Outcomes
i‑CBT versus Wait List/Treatment
as Usual/Minimal Attention
There was evidence that i-CBT was more effective than wait list/treatment
as usual/minimal attention in the reduction of PTSD symptoms postinter-
vention (kappa = 8; n = 560; SMD = –0.60; CI = –0.97 to –0.24). However,
these effects were not maintained at follow-­up of 3–6 months (kappa = 3;
n = 146; SMD = –0.0; CI = –0.64 to 0.04). The postintervention effect size
was greater for studies in a subgroup analysis of only trauma-­focused i-CBT
(trauma focused [kappa = 4; n = 177; SMD = –1.04; CI = –1.57 to –0.51] vs.
non-­trauma-­focused). There was also evidence for greater effect in a sub-
group analysis of only guided i-CBT (kappa = 6; n = 391; SMD = –0.86; CI =
–1.25 to –0.47). There was evidence of greater dropout from i-CBT than wait
list/treatment as usual/minimal attention (kappa = 8; n = 585; RR = 1.39;
CI = 1.03 to 1.88). There was evidence that i-CBT was more effective than
wait list/treatment as usual/minimal attention in the reduction of symp-
toms of depression and anxiety postintervention and at follow-­up of less
than 6 months. There was also evidence that i-CBT was more effective than
wait list/treatment as usual/minimal attention postintervention in terms of
improvement in quality of life.
E‑Mental Health 331

i‑CBT versus i‑Non‑CBT

I-CBT showed no benefit when compared to i-non-CBT in the reduction
of PTSD symptoms postintervention (kappa = 2; n = 82; SMD = –0.08; CI =
–0.52 to 0.35), at follow-­up of less than 6 months (kappa = 2; n = 65; SMD =
0.08; CI = –0.41 to 0.57), and at follow-­up of 6–12 months (kappa = 1; n = 18;
SMD = –8.83; CI = –17.32 to –0.34). There was also no evidence of greater
dropout from i-CBT than i-non-CBT (kappa = 2; n = 132; RR = 2.14; CI =
0.97 to 4.73). There was insufficient data to conduct any subgroup analyses.
There was no evidence of a difference between i-CBT and i-non-CBT on
measures of depression or anxiety at postintervention or follow-­up at less
than 6 months. There was evidence from one study of a greater reduction in
depression and anxiety at follow-­up of over 6 months for the i-CBT group.

Summary
I-CBT may have been more effective than a wait list in reducing PTSD symp-
toms, depression, and anxiety posttreatment. However, there was no signifi-
cant difference between the two groups on measures of quality of life. The
magnitude of effect was smaller than that found in comparisons of therapist-­
administered trauma-­focused CBT with wait list or usual care. There was no
significant difference between i-CBT and i-non-CBT on any measure post-
treatment. Only two small studies made this comparison; they showed that
i-CBT was no more effective in reducing severity of PTSD symptoms, anxi-
ety, and depression at 12-month follow-­up. Although the review found some
beneficial effects of i-CBT for PTSD, the quality of the evidence was very low
due to the small number of included trials. It was concluded that further
work is required to determine noninferiority to current EBPs.

Clinical Recommendations

Understanding and overcoming traditional barriers to treatment and pro-

viding alternatives that serve to maximize the number of individuals with
PTSD who are able to quickly access and engage in EBP is an important
public health concern. Demanding approximately 80% less therapist time
than the EBPs delivered by a therapist, e-­mental health interventions for
PTSD have the potential to maximize the use of health care resources and
widen access to effective treatment. They also have the potential to increase
therapeutic capacity and reduce waiting lists, thereby enabling timely inter-
vention and resolution of traumatic stress symptoms, which has numerous
likely benefits including reduced distress and minimized interference with
normal role functioning. E-­mental health for PTSD also provides the scope
to overcome many traditional barriers to treatment, including difficulties
332 Treatments for Adults

committing to weekly appointments due to work, family demands, child care

commitments, or transport issues. There are many factors that need to be
taken into account when considering the clinical use of e-­mental health.
While studies to date have found some beneficial effects of i-CBT for PTSD,
the quality of the evidence is low. The approach shows promise. However,
further work is required to establish noninferiority to current first-line inter-
ventions before they are used in routine clinical care.

Suitability
E-­mental health interventions are not intended to replace face-to-face inter-
ventions. Since the effect of e-­mental health interventions for the treatment
of PTSD does not currently appear to be as strong as that found in reviews
of face-to-face therapy, it is likely that careful selection of individuals is the
best strategy for routine clinical use. E-­mental health is particularly appro-
priate as an initial intervention in a stepped or stratified pathway of care.
According to these models, additional treatment becomes available if and
when the individual fails to benefit sufficiently from a less intense form
of intervention, such as e-­mental health (Bower & Gilbody, 2005). At least
a proportion of individuals are likely to respond to e-­mental health and
require no further intervention, which fits well with the principles of pru-
dent health care.

Maximizing Engagement
Despite initial easy access, many users do not fully engage with interven-
tion content and may fail to receive an “adequate dose” of the intervention.
Cost-­effective means of encouraging full use of e-­mental health interven-
tions remain to be developed, whether these are human-­administered or
technological and automated. Further work is needed to explore rates of
uptake and retention in trials of Internet-­based interventions and to develop
treatment protocols that maximize engagement.

Therapist Training
Internet-­based interventions are delivered as stand-alone self-help therapies
or with input from a trained professional or paraprofessional, with the great-
est support for guided interventions (Lewis et al., 2012; Spek et al., 2007).
There is a need for therapists to be appropriately trained in the delivery of
e-­mental health interventions (Ybarra & Eaton, 2005). Although the major-
ity of interventions are based on cognitive-­behavioral principles, methods of
delivery diverge considerably from standard face-to-face therapy. For exam-
ple, conveying information, encouragement, and instructions in a text-based
format is very different to doing so verbally. There are many ways in which
E‑Mental Health 333

interventions may be facilitated. Some interventions require facilitators to

monitor participants and only intervene when necessary or requested by the
consumer. Other interventions incorporate more intensive face-to-face input
from a facilitator that is more akin to delivering a brief form of therapy.
Training needs to thereby vary according to the requirements of the specific
intervention. We currently know very little in relation to therapist factors
that affect the uptake and outcome of e-­mental health (Lewis et al., 2018).
It represents a different way of working, which is likely to suit some thera-
peutic styles more than others. Studies have also found that therapists are
less positive about e-­mental health than individuals with PTSD (Waller &
Gilbody, 2009). Work is required to engage clinicians and determine ways
of optimally embedding e-­mental health. Future work should ascertain the
optimal balance between minimizing therapist input and maximizing out-
come. It would also be useful to explore ways of augmenting programs with
built-in self-­reinforcement strategies (e.g., collection of rewards for comple-
tion of assignments within a program) to reduce or eliminate the need for
therapist assistance.

Intervention Development and Evolution

E-­mental health interventions should be as visually appealing and techno-
logically advanced as other websites (Ybarra & Eaton, 2005). Consumers are
known to rate the credibility of information based partly on the look and
functionality of websites. Technology evolves rapidly. Productive collabora-
tions with Web developers are therefore necessary to ensure that interven-
tions meet the needs of consumers from a technological point of view. Data
security is also an important consideration. It is vital that researchers and
providers have up-to-date knowledge of the security measures that will be
necessary to protect the integrity of e-­mental health interventions (Bennett
et al., 2010). There is a need for the inclusion of a list of the risks and ben-
efits in the consent forms for e-­mental health interventions (Ybarra & Eaton,
2005).

Implementation
Implementation of effective e-­mental health into routine care is an impor-
tant consideration. There is discontinuity between academic-­based innova-
tions and their commercial application. This is partly due to problems with
the ownership of intellectual property by universities and the need for com-
panies to commercially develop and maintain the technology. A similar issue
arises when technologies are developed with the intention of noncommer-
cial access, due to problems of funding routine delivery when that is not the
accepted role of individual investigators, research institutions, or funding
organizations.
334 Treatments for Adults

Research Recommendations

Here, we offer a number of recommendations in terms of the future research

that will be required to advance the field.

Maximizing the Efficacy of i‑CBT for PTSD

The findings of a smaller effect size than reviews of therapist-­delivered CBT
indicate that the interventions developed to date may not be optimal. A pos-
sible explanation is that the i-CBT programs evaluated to date have failed
to deliver a sufficient “dose” of trauma processing. Previous research has
indicated that PTSD sufferers were able to tolerate a larger dose of exposure
than included in the original prototype, and later iterations of the program
had a greater trauma focus with improved results and no reported adverse
effects (Lewis et al., 2013). Further research is also needed to determine
ways of merging the wide-­ranging capabilities of e-­mental health technolo-
gies (e.g., interactivity and automation) to maximize their influence (Ruzek
et al., 2016). Further work is also needed to maximize the maintenance of
treatment gains and improve longer-­term outcomes.

Determining Factors Associated with Treatment Response

and Dropout
There is a continued need to explore predictors of outcome and dropout,
such as participant age, trauma type, levels of computer literacy, and symp-
tom severity. This will provide a greater understanding of the individual
characteristics that are likely to be associated with positive responses to
e-­mental health (Hamburg & Collins, 2010).

Exploring Mechanisms of Change

Little is known regarding the mechanisms of change associated with
e-­mental health interventions for PTSD (Andersson, Carlbring, Berger, Alm-
löv, & Cuijpers, 2009). Further work is needed to determine the moderators
and mediators of treatment effects (Andersson, 2009). This is especially per-
tinent because the field has so far failed to find an advantage of CBT-based
interventions in direct comparison with non-CBT-based approaches (Litz
et al., 2007; Spence et al., 2014). This contradicts findings from the wider
PTSD literature (Bisson, Roberts, Andrew, Cooper, & Lewis, 2013; Jonas et
al., 2013) and warrants further scrutiny.

Establishing Effectiveness
Large multicenter effectiveness trials with nested process evaluation (aim-
ing to explain how complex interventions work) are needed to improve the
E‑Mental Health 335

evidence base and for us to become able to more confidently recommend

e-­mental health for PTSD. More research is also needed to establish the effi-
cacy and feasibility of e-­mental health for those exposed to war or disaster
(Ruzek et al., 2016).

Economic Evaluation
There have been no economic evaluations of e-­ mental health interven-
tions for PTSD, and RCTs to date have not reported on costs incurred
through delivery of the interventions (Lewis et al., 2018). Since cost is a
major driving force behind the development and implementation of Web-
based interventions, rigorous economic evaluations are needed to ascertain
the cost-­effectiveness of e-­mental health. The initial investment required
to create, implement, and evaluate e-­mental health interventions is signifi-
cant, and should not be underestimated (Donker et al., 2015). There are
also costs associated with maintaining and updating websites and mobile
phone apps (Christensen et al., 2002). Economic evaluations comparing the
cost-­effectiveness of different methods of delivering mental health services
would serve a useful purpose. Only after thorough examination of the cost-­
effectiveness of e-­mental health can we be certain that the approach makes
good use of limited resources. There is also some concern that increased
awareness of mental health due to e-­mental health initiatives may have the
short-term effect of overburdening already stretched services (Christensen
et al., 2002).

Acceptability
We know little regarding the acceptability of e-­ mental health. Work is
needed to determine the acceptability of this approach to both users and
clinicians. There is also a need to measure and report adverse events aris-
ing from e-­mental health. As outlined earlier, we know little regarding the
acceptability of e-­mental health to minority and culturally diverse groups
(Richards, 2004). The use of e-­mental health may raise questions of acces-
sibility and potential exclusion, especially with regard to older generations,
that also warrant attention.

Summary and Conclusions

Although a substantial body of literature supports trauma-­focused psycho-

logical therapies as effective treatments for PTSD, numerous barriers, such
as the cost of delivering therapies, the availability of suitably qualified thera-
pists, and the availability of therapy in geographically remote areas, preclude
timely intervention. In response, there has been a growing interest in using
the Internet as a platform for the delivery of psychological therapy. This
336 Treatments for Adults

has the capacity to reduce the cost of effectively delivering evidence-­based

therapy and has the potential to overcome many other barriers that cur-
rently limit the availability and uptake of treatment. The collective evidence
to date supports the promise of i-CBT as a treatment option for PTSD. How-
ever, further work is required to maximize the efficacy of programs, estab-
lish noninferiority to current first-line interventions, explore mechanisms
of change, establish optimal levels of guidance, explore cost-­effectiveness,
measure adverse events, and determine predictors of efficacy and dropout.

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C H A P TE R 19

Complementary, Alternative,
and Integrative Interventions
Ariel J. Lang and Barbara Niles

Ttechniques)
reatments that are not part of standard Western medicine are typically
classified as “complementary” (i.e., used in combination with established
or “alternative” (i.e., used in place of typical practice) (National
Center for Complementary and Integrative Health [NCCIH], 2018a). Interna-
tionally, estimates of all health-­related use of complementary and alternative
practices generally fall in the range of 20–30% (Kemppainen, Kemppainen,
Reippainen, Salmenniemi, & Vuolanto, 2018; Peltzer, Pengpid, Puckpinyo,
Yi, & Anh le, 2016; Rossler et al., 2007), with substantial differences noted
based on regional and sociodemographic factors (Gureje et al., 2015; Thir-
thalli et al., 2016). Mental health care in low- and middle-­income countries,
for example, is heavily composed of alternative approaches, in part because
of the lack of availability of pharmacotherapy or evidence-­based psycho-
therapy (Gureje et al., 2015). Within the United States, the National Health
Interview Survey 2017 documented generally stable rates of use over the
past decade, with the exception of continued increases in yoga and medita-
tion (NCCIH, 2018b). Both the U.S. military health care system (Herman,
Sorbero, & Sims-­Columbia, 2017) and U.S. Department of Veterans Affairs
(VA; Taylor, Hoggatt, & Kligler, 2019) report providing complementary and
alternative care to a substantial number of clients, with mental health and
pain being the most common reasons for seeking such care. As use of these
techniques becomes more common and they gain empirical support, how-
ever, approaches that are considered conventional medicine will change.
“Integrative” care has been defined by the National Center for Com-
plementary and Integrative Health (2018a) as “a holistic, patient-­focused
approach to health care and wellness—­often including mental, emotional,

343
344 Treatments for Adults

functional, spiritual, social, and community aspects—­and treating the whole

person rather than, for example, one organ system.” Although such pro-
grams exist and integrative care is an important aspiration, the empirical
literature is particularly lacking in this area. To our knowledge, there has
been no systematic evaluation of integrative care approaches, and assess-
ment tools are much better developed for tracking symptom change than
wellness.
The purpose of this chapter is to review the current evidence for mind–
body interventions, which is the most commonly used class of complemen-
tary and alternative treatments for posttraumatic stress disorder (PTSD).
In contrast to the Cartesian dualistic view of the mind and body as distinct
and separable, mind–body therapies focus on treating the whole person
with the intention to promote overall health and well-being. The NCCIH
(2017b) further specifies that mind–body techniques are “administered or
taught to others by a trained practitioner or teacher” such as a yoga instruc-
tor or acupuncturist. Dietary and herbal supplements, the other major class
of complementary or integrative treatments defined by the NCCIH, are
largely unstudied in PTSD; the single trial meeting criteria for this review is
included here as well.
The rationale for the use of complementary, alternative, and integrative
(CAI) approaches for PTSD is twofold. Pragmatically, these are interventions
that individuals with PTSD are seeking out. The reasons for this may involve
seeking alternatives to standard practices (e.g., to avoid pharmacotherapy
or trauma-­focused therapy) or the desire for a more holistic approach (Kro-
esen, Baldwin, Brooks, & Bell, 2002). As mental health professionals, we
have a responsibility to understand the utility of these treatments so that we
can responsibly guide clients in selecting an effective care plan. For some, an
alternative intervention may provide sufficient symptom relief. For others,
these techniques may be used in a complementary manner to facilitate entry
into other types of care, for example, by enhancing one’s perceived cop-
ing ability or trust in mental health professionals. Given that residual symp-
toms or continued functional impairment are common after even the most
efficacious treatments (Schnurr & Lunney, 2015; Steenkamp, Litz, Hoge, &
Marmar, 2015), there also may be a place for complementary interventions
to target specific symptom types (e.g., reducing residual hyperarousal or
enhancing positive affect) or functional areas (e.g., social connectedness)
or to support coping with persistent symptoms. Theoretically, integrative
approaches may be valuable for their ability to systematically target different
mechanisms that maintain or are disrupted by the disorder. PTSD is increas-
ingly understood as a systemic illness (McFarlane, 2017) associated with
accelerated cellular aging and cardiometabolic morbidity (Wolf & Schnurr,
2016). Given the complex interplay of emotional, cognitive, and physical
symptoms associated with PTSD, a whole-body treatment approach becomes
necessary, an area in which CAI interventions show increasing promise.
Complementary, Alternative, and Integrative Interventions 345

The techniques reviewed in this chapter have been compiled into four
groupings: meditation, acupuncture, yoga, and “other,” which includes a
variety of interventions for which only one study met the criteria for inclu-
sion.

1. Meditation can be described as a process that cultivates greater

awareness of or a different relationship to the mind. The broad term,
however, encompasses a large variety of techniques that vary consid-
erably in terms of the mechanisms by which PTSD may be affected
(refer to Lang et al., 2012, for additional discussion).
2. Acupuncture involves stimulating specific points on the body, typi-
cally by applying thin needles that are manipulated by hand or using
electrical current (NCCIH, 2017a).
3. Yoga describes a practice that typically combines physical postures,
regulation of the breath, and techniques to cultivate attention (Gard
et al., 2014), with the emphasis on each of these factors varying
greatly among types of practice.
4. Other
• Physical activity refers to various types of exercise, including aero-
bic and resistance-­based activities, delivered for therapeutic ben-
efit.
• Music therapy may include creating or playing music, singing,
moving to, or listening to music.
• Nature–­adventure includes a variety of adventure-­based activities
in natural outdoor settings.
• Saikokeishikankyoto (SKK) is a traditional Japanese herbal for-
mula.

Table 19.1 provides a summary of the interventions for which studies

met criteria for inclusion within the Posttraumatic Stress Disorder Prevention
and Treatment Guidelines advanced by the International Society for Trau-
matic Stress Studies (ISTSS) and the level of evidence for each approach.

Summary and Appraisal of the Evidence

Meditation
The mantram repetition program (MRP) is a practice that involves silent
repetition of a spiritual word or phrase (called a mantram), slowing thoughts,
and cultivation of “one-­pointed attention” (Bormann, Thorp, Wetherell, &
Golshan, 2008). Mantram repetition showed no benefit when compared
with wait list or usual care. The initial feasibility study (Bormann et al.,
2008) involved 31 veterans, who were assigned to MRP or a delayed treat-
ment control. This pilot study was intended to assess feasibility, acceptability,
346 Treatments for Adults

TABLE 19.1. Summary of ISTSS Guidelines for CAI Interventions

Meditation
Insufficient Evidence to Recommend—Mantram repetition, mindfulness-based stress reduction

Acupuncture
Intervention with Emerging Evidence—Acupuncture
Insufficient Evidence to Recommend—Electroacupuncture

Yoga
Intervention with Emerging Evidence—Sudarshan Kriya (SKY)/Kripalu/trauma informed

Other
Intervention with Emerging Evidence—Saikokeishikankyoto (SKK), somatic experiencing
Insufficient Evidence to Recommend—Group music therapy, nature adventure therapy,
physical exercise

and initial clinical signal, and should be understood in this context. The sec-
ond study (Bormannm Thorp, Wetherell, Golshan, & Lang, 2013) was also
conducted with a veteran sample (n = 146), comparing MRP plus usual care
to MRP alone. Strengths of the trial include its size and use of a gold stan-
dard outcome measure, the Clinician-­Administered PTSD Scale (CAPS). A
limitation, however, is the lack of control for the nonspecific effects of the
group meetings.
MRP nevertheless showed a positive effect when compared with individ-
ual present-­centered therapy (Bormann et al., 2018); it should be noted that
this trial is not reflected in the evidence rating, which was based on perfor-
mance as compared to wait list or treatment as usual. This most recent trial
took place in two VA facilities (n = 173) and was designed to address some of
the limitations of the previous studies (e.g., active comparison group, more
than one site). The intervention was delivered on an individual basis in eight
weekly 60-minute sessions by trained therapists. A primary limitation of the
studies of MRP is generalizability. Because all three randomized trials have
been conducted with veterans, it is unclear how the intervention would per-
form in different populations. Based on the findings from the two older
studies that used wait-list or treatment-­as-usual comparitors, there is Insuf-
ficient Evidence to Recommend MRP at this time. Because of the positive find-
ings in the most methodologically rigorous study using an active treatment
comparitor, however, additional studies of MRP are warranted.
Mindfulness-­based stress reduction (MBSR) is a program that uses a
variety of techniques to cultivate the state of mindfulness (i.e., nonjudgmen-
tal present-­moment awareness; Kabat-Zinn, 1994). It is typically delivered
in a series of weekly 2.5-hour group meetings along with a day-long retreat.
Complementary, Alternative, and Integrative Interventions 347

MBSR showed no benefit when compared with wait list or usual care in a
veteran sample (Kearney, McDermott, Malte, Martinez, & Simpson, 2013).
Mindfulness training delivered via tele-­health (two sessions in person
and six by telephone) showed a positive effect for veterans when compared
with psychoeducation also delivered via tele-­health (Niles et al., 2012). This
brief treatment was based on the tenets of MBSR but was delivered in indi-
vidual sessions and did not include the full program. It is also notable that
the improvements were not sustained over a 6-week follow-­up.
There was no evidence of a difference between MBSR and present-­
centered therapy delivered in group sessions over three randomized con-
trolled studies. A pilot study by Bremner and colleagues (2017) included 26
veterans, who were assessed using CAPS. The much larger trial by Polusny
and colleagues (2015) involved 116 veterans. A limitation of this study is that
treatment length was not matched, so those in the MBSR condition partici-
pated in 20 hours of group plus a daylong retreat, whereas those in present-­
centered groups received 13.5 hours of intervention. Finally, Davis and col-
leagues (2018) assigned 214 veterans from three VA clinics in the southeastern
United States to eight 90-minute group sessions of MBSR or present-­centered
therapy. Only 55% of the consenting group in this trial completed the post-
treatment assessment. Thus, the conclusion based on the trials of MBSR and
related techniques is that there is Insufficient Evidence to Recommend. Given that
two trials are large and methodologically rigorous, it is questionable whether
additional study of MBSR in the veteran population would lead to a different
conclusion. It is possible, however, that results would be different if the treat-
ment were delivered to a different population of individuals with PTSD.
Three additional studies that were not published at the time of the
meta-­analysis warrant mention. Nidich and colleagues (2018) conducted a
large (n = 203) randomized controlled trial (RCT) of transcendental medi-
tation (TM), prolonged exposure (PE), and a health education control in a
VA medical center. TM is a specific type of silent meditation developed by
Maharishi Mahesh Yogi that involves repetition of a sound, that is, a mantra,
to facilitate meditation (Travis & Shear, 2010). TM and the education control
were delivered in groups, and PE was administered individually; all interven-
tions took place over 12 weeks. The primary outcome was PTSD severity as
measured by CAPS. The results suggest that TM was not inferior to PE, and
both conditions were superior to health education. In addition, Bellehsen
and colleagues recently completed a pilot study of TM compared to usual
care in a sample of 40 veterans with PTSD. Those in the TM group showed
significantly greater change in symptoms as measured by CAPS at posttreat-
ment (Bellehsen, Stoycheva, Cohen, & Nidich, 2017).
Lang and colleagues (2019) conducted a small randomized trial of com-
passion meditation as compared to a relaxation control in a sample of 28 vet-
erans. Compassion meditation is a contemplative meditation based on Bud-
dhist philosophy, but operationalized in a secular way. It involves developing
348 Treatments for Adults

the heartfelt wish that others and oneself may be at peace and satisfied with
their lives; such compassion is cultivated through recognition of common
humanity. Both interventions were delivered in 10, 90-minute group ses-
sions, and outcomes were assessed via CAPS. Compassion meditation led to
significantly greater change in PTSD symptoms than the relaxation control
condition.
In summary, meditation has received considerable empirical scrutiny
in U.S. veteran populations, but it should be noted that randomized stud-
ies in civilian samples are absent. There is variability in outcomes based on
the type of meditative practice that was implemented, so it is important to
underscore that meditation is not a single intervention but rather a class
of interventions. The consistent findings from large and methodologically
sound trials of MBSR for PTSD suggest that it is unlikely to become a stand-
alone PTSD intervention. That said, decades of research indicate that MBSR
reduces depression and anxiety, improves quality of life and physical func-
tioning, and is not associated with any notable adverse reactions (Grossman,
Niemann, Schmidt, & Walach, 2004; Khoury, Sharma, Rush, & Fournier,
2015), so it may be a useful complement to PTSD care for certain comor-
bidities. Compassion meditation shows some preliminary clinical promise,
suggesting that the contemplative framework supporting change in social
connectedness may augment the effect of mindfulness-­based meditation.
It is notable that some of the strongest results are associated with the
mantra-­based practices, MRP and TM. Although these practices share the
repetition of a mantra, there are differences in the practices. In TM, the
mantra is chosen by the course instructor and kept private, whereas the
individual selects a personally meaningful spiritual word in MRP and may
share the word as desired. In addition, TM is a sitting meditation (often
operationalized as sitting quietly for 20 minutes twice per day), whereas
mantram repetition can be accomplished in any position or location and
for any amount of time. It is unclear the extent to which the mechanisms
of change in PTSD symptoms are affected by these differences. The most
recent evidence about MRP is very promising, and two papers now suggest
that it is particularly effective at reducing hyperarousal (Bormann et al.,
2013; Crawford, Talkovsky, Bormann, & Lang, 2019), which is the most com-
mon residual symptom type following current empirically supported treat-
ments (Schnurr & Lunney, 2015). The effect of MRP has also been tied to
spirituality (Bormann, Liu, Thorp, & Lang, 2011), which may be appealing
for some treatment-­seeking individuals. The recently published trials of TM
are also quite promising. It has been conjectured that TM may be effective
at reducing physiological arousal (Lang et al., 2012), although this was not
examined in the recent trial. Ultimately, it will be important to standard-
ize protocols so that they may be reliably evaluated and replicated, and to
understand the mechanisms that differentiate the types of meditation to
best apply meditation-­based interventions to clinical problems.
Complementary, Alternative, and Integrative Interventions 349

Acupuncture
Acupuncture showed a positive effect when compared with wait list in a sam-
ple of community-­dwelling adults based on a self-­report measure of PTSD. In
the same study, there was no evidence of a difference between acupuncture
and cognitive-­behavioral therapy with a trauma focus (CBT-T). The primary
limitations of this study are that the sample was relatively small, interven-
tion type is confounded with provider, and the highly educated, treatment-­
seeking sample may not represent the typical population of individuals with
PTSD. A second study with an active comparator found no evidence of a
difference between electroacupuncture and paroxetine. This study involved
PTSD related to earthquake exposure in China. Thus, acupuncture is con-
sidered an Intervention with Emerging Evidence.
Of note, one additional study is relevant to the clinical use of acupunc-
ture. Engel and colleagues (2014) randomized 55 U.S. military service mem-
bers with PTSD to usual care or usual care plus acupuncture. Outcomes were
evaluated using both CAPS and a self-­report measure of symptomatology.
The group that received acupuncture showed significantly greater clinical
improvement, although the design does not disentangle the effect of addi-
tional intervention from that of acupuncture in particular. Nonetheless, the
trial suggests generalizability of the aforementioned studies and supports
the need for additional study of the practice.

Yoga
Yoga showed a positive effect when compared with wait list, assessment-­only
control, or attention control, leading to its designation as an Intervention with
Emerging Evidence. The studies providing evidence for yoga, however, are
largely pilot studies. Carter and colleagues (2013) implemented Sudarshan
Kriya (SKY) yoga, a breath-­based practice, as compared to wait list with 31
Australian Vietnam veterans. Seppala and colleagues (2014) similarly exam-
ined SKY versus wait list in 21 U.S. veterans. Both Mitchell and colleagues
(2014) and Reinhardt and colleagues (2018) compared Kripalu yoga to an
assessment-­only control. Mitchell and colleagues’ work involved 20 women
and noted that change in hyperarousal may have been a key mechanism of
change in the yoga condition. Reinhardt and colleagues enrolled a group of
51 U.S. veterans but had considerable attrition, resulting in a final analyzed
group of 17. Both of these studies found no signficant differences in PTSD
outcomes between the yoga and control groups. All studies have used stan-
dard interview-­based or self-­report tools. The largest trial was conducted by
van der Kolk and colleagues (2014). They compared trauma-­informed yoga
to supportive health education with 64 women, using CAPS to evaluate out-
comes, and found significantly greater symptom reductions for those in the
yoga condition.
350 Treatments for Adults

Although yoga is characterized as an emerging intervention, the het-

erogeneous nature of the practice limits the conclusions that can be drawn.
There have been efforts to quantify key aspects of yoga (Groessl et al., 2015),
and it will be important to utilize such tools to understand active ingredi-
ents and develop standardization to allow for replication and dissemination
of efficacious protocols. The data on the use of yoga come from veterans
and women, so future studies should consider issues of generalizability. Also
of note is that only one trial utilized an active control condition. It will be
important to examine whether or not yoga’s effect is based on more than
nonspecific therapeutic factors (e.g., expectancies, group support). Whether
yoga’s impact differs from that of other types of physical activity or relax-
ation may also help to understand mechanisms of action (for additional dis-
cussion of mechanisms of change, refer to Wells, Lang, Schmalzl, Groessl,
& Strauss, 2016). Finally, yoga is an experiential practice, so the optimal
frequency and duration of practice may vary considerably.

Other Techniques
Saikokeishikankyoto
Saikokeishikankyoto (SKK), a Japanese herbal formula, was compared to
a no-­treatment control with 47 Japanese outpatients diagnosed with PTSD
(Numata et al., 2014). Participants in the SKK group received the herbal
formula 3 times per day for 2 weeks. After treatment, the SKK group was
significantly more improved than the control group on the Impact of Events
Scale—­Revised with no serious adverse events. The study was limited by
use of a no-­treatment rather than placebo control, and it did not include
a follow-­up assessment to determine whether the effects were lasting. On
the basis of the aforementioned study, this herbal remedy is currently con-
sidered an Intervention with Emerging Evidence in the treatment of PTSD,
although additional research is needed to confirm these findings and to
examine the intervention’s generalizability outside of Japan.

Somatic Experiencing
This therapeutic process focuses on awareness and regulation of internal sen-
sations of physiological arousal within the context of psychotherapy (Levine,
2010; Payne, Levine & Crane-­Godreau, 2015). The goal of the approach is
to reduce physiological activation through increased ability to tolerate body
sensations and related emotions. Clients acquire skills, such as body aware-
ness, and focus on positive memories, which they are then directed to use to
self-­regulate their arousal and emotions. This therapy differs from psycho-
therapies with a trauma focus (such as PE; see Riggs, Tate, Chrestman, &
Foa, Chapter 12, this volume) in that written or oral retelling of specific trau-
matic events is not required. However, this intervention contains elements
Complementary, Alternative, and Integrative Interventions 351

that may be considered trauma exposure. Similar to interventions with a

trauma focus, clients are instructed to engage with traumatic memories
to elicit high arousal. Clients then practice using the skills to reduce the
arousal, eventually leading to increased tolerance and reductions in distress
related to posttraumatic arousal.
Brom and colleagues (2017) compared somatic experiencing to wait list
in a sample of Israeli individuals with PTSD. The approach showed a positive
effect when compared with wait list. This positive result and the good size
of the trial (n = 60) led to it being classified as an Intervention with Emerging
Evidence, although several limitations should be noted. Because of the lack
of an active comparator, it is possible that nonspecific factors influenced the
result. The single site of the trial also raises the possibility that results may
not generalize. Somatic experiencing sits at the intersection between inter-
ventions with a trauma focus and CAI, incorporating elements of both in an
integrative fashion. Future research can be designed to empirically evalu-
ate the benefit of integrated programs and determine whether components
combine in additive or synergystic ways to improve outcomes.

Group Music Therapy

Carr and colleagues (2012) compared group music therapy to wait list in a
sample of 17 individuals in the United Kingdom who remained symptomatic
after cognitive-­behavioral therapy (CBT). Group music therapy showed a
positive effect when compared with wait list, but there is Insufficient Evidence
to Recommend the approach due to the small sample size.

Nature–Adventure Therapy
Although a number of programs purport to support recovery from PTSD
through engagement with a variety of adventure-­based activities in natural
settings, only one study has employed a randomized design to evaluate the
approach. Gelkopf, Hasson-Ohayon, Bikman, and Kravetz (2013) enrolled
22 Israeli veterans with combat-­related PTSD in a year-long (delivered in
weekly 3-hour meetings) program of sailing and other ocean-based activities
and compared outcomes with those of 20 veterans who were on a wait list.
Nature–­adventure therapy showed no benefit when compared with wait list,
leading to Insufficient Evidence to Recommend.

Physical Exercise
Physical activity interventions for PTSD showed no benefit when com-
pared with wait list or usual care, leading to an Insufficient Evidence rec-
ommendation. Although the evidence to recommend physical activity is
currently insufficient for the treatment of PTSD symptoms, physical activ-
ity should nonetheless be recommended universally as a part of health
352 Treatments for Adults

maintenance. PTSD is associated with increased morbidity and mortality

(Boscarino, 2006), including cardiovascular disease (Ahmadi et al., 2011);
poor physical fitness has been associated with increased symptomatology
(Vancampfort et al., 2017); and evidence suggests that exercise supports
physical health among those with mental health problems (Stubbs et al.,
2018).
The current designation for exercise is based on two studies. Goldstein
and colleagues (2018) conducted a pilot trial (n = 47) of a 12-week integrated
(aerobic and resistance exercise with some mindfulness-­ based practices
delivered in three weekly 1-hour classes) group exercise program as com-
pared to wait list. The integrated exercise program showed greater reduc-
tions in PTSD symptoms. Rosenbaum, Sherrington, and Tiedemann (2015)
examined the effect of the addition of an exercise program (six 30-minute
sessions over 2 weeks involving resistance training and walking) to usual
care in a sample of 81 individuals who were in an inpatient program for
PTSD. Although they did not observe a benefit with regard to PTSD symp-
toms, their data suggest the possibility of additional benefits such as reduced
waist circumference and improved sleep quality.
It is critically important to consider broader health impacts in future
studies of exercise for PTSD; future recommendations about the inclusion
of exercise in a recovery plan should be considered based on both physi-
cal and mental health outcomes, particularly given the increased morbid-
ity and mortality associated with PTSD. In addition, a good deal remains
to be understood about the impact of physical activity of individuals with
PTSD. Both of the exercise studies included aerobic and resistance-­based
exercise, and it is unknown whether different types of exercise have a differ-
ent impact on symptomatology. A recent review suggested several possible
mechanisms by which aerobic exercise might reduce PTSD symptoms (Heg-
berg, Hayes, & Hayes, 2019): exposure and desensitization to interoceptive
arousal, enhanced cognitive function, exercise-­induced neuroplasticity, nor-
malization of endocrine function, and reductions in inflammation. Future
studies can elucidate which of these mechanisms are at play to guide how
to successfully integrate exercise with traditional psychotherapies for PTSD.
For example, Fetzner and Asmundson (2015) examined ways in which exer-
cise may be best delivered to enhance exposure and desensitization. They
compared the impact of aerobic exercise (six sessions in 2 weeks) across
three conditions: attention to somatic arousal, distraction from somatic
arousal, or no distractions/prompts. Although all groups showed reductions
in symptoms, this was attenuated in the interoceptively focused group. We
caution against concluding that distraction is useful, however, as longer-­
term outcomes may differ. In addition, systematic exposure to interoceptive
cues, which may differ based on the type and intensity of exercise, has been
suggested as a way to augment treatment response (Wald & Taylor, 2007),
meaning that exercise could play an important complementary role when
engaging in therapy with a trauma focus.
Complementary, Alternative, and Integrative Interventions 353

Practical Delivery of the Recommendations

Despite the paucity of empirical evidence presented in the ISTSS guide-

lines to support the use of CAI approaches in the treatment of PTSD, three
treatments—­acupuncture, yoga, and somatic experiencing—­are cautiously
recommended as interventions with emerging evidence. Although there
remains insufficient evidence to recommend meditation, several approaches
show clinical promise and recommendations may change as evidence accu-
mulates. Given the nascent state of the literature on CAI therapies for PTSD,
it is premature to recommend any as first-line treatments for PTSD, and
additional research is needed to determine how and when these treatments
might be most efficacious when used adjunctively. Yoga and acupuncture
are mind–body treatments that could be delivered to complement standard
psychotherapies, such as treatments with a trauma focus (i.e., prior to, dur-
ing, or following standard therapies) or as stand-alone treatments (for indi-
viduals who choose not to pursue psychological therapies). In a different
approach, somatic experiencing therapy integrates mind–body components
with more traditional “talk therapy” components within the treatment. With
a focus on the body sensations and emotions that arise with trauma mem-
ories, individuals learn to tolerate negative feelings and to regulate their
physiological reactions.
As the evidence base of methodologically rigorous trials of CAI treat-
ments continues to grow, it is likely that additional CAI treatments soon
will accrue sufficient evidence to recommend them. For example, as noted
previously, since the review of evidence for these guidelines was completed,
a methodologically rigorous study of transcendental meditation was pub-
lished (Nidich et al., 2018) that indicates it may be a promising treatment
for PTSD. Similarly, the strongest evidence to date for mantram repetition
involves a study with a nonspecific psychotherapy control (Bormann et al.,
2018), which falls outside the a priori procedures for recommendation in
these treatment guidelines.
It is important to acknowledge, however, that many CAI therapies do
not target reductions in specific symptoms. Because change in PTSD symp-
toms is a critical metric for evaluating PTSD treatments, it is possible that
their contributions are underestimated. Mindfulness, which is a component
of many of these approaches, encourages present-­moment awareness and
aims to reduce the struggle against distressing sensations. A major focus
of these therapies is on changing one’s relation to one’s physical and mental
states, rather than changing symptoms themselves. For example, the num-
ber of intrusive trauma memories one has over a week may not change sub-
stantially, but the distress associated with the memories may recede and the
ability to engage in other life activities may improve. Thus, a shift in the
methods used to evaluate outcomes for CAI therapies may be required to
capture changes such as distress tolerance, sense of well-being, or enhance-
ment of valued life goals. The need for such standards for the evaluation
354 Treatments for Adults

of CAI may, in turn, prompt broader understanding of the impact of other

types of interventions to the benefit of individuals looking to recover from
traumatic experiences.
An important caveat to the use of CAI interventions is that they may
foster avoidance and/or cultivate dependence if applied inappropriately. A
well-­meaning instructor, for example, may communicate that stimuli trig-
gering strong emotions (e.g., certain asanas or vigorous exercise) should
be avoided, inadvertently reinforcing the fear that internal experiences are
harmful. Similarly, a technique may be misapplied in an attempt to avoid
internal experience, rather than as a way to cope while expanding function-
ality. Thus, it is critical that CAI practitioners be provided with a basic under-
standing of processes that contribute to the development and maintenance
of PTSD. Alternatively, an individual might misattribute change to a par-
ticularly skilled instructor rather than the individual’s efforts and become
reliant on seeing that instructor several times per week. In such cases, clients
should be encouraged to accept responsibility for their own recovery, such as
developing their own practice outside of session or using the skills developed
(e.g., mindful awareness) to face other life challenges. Therapists should be
alert to the possibility that, in some cases, client engagement in CAI inter-
ventions can distract from, rather than augment, the work of evidence-­based
psychological treatments for PTSD, such as therapies with a trauma focus.
Despite the potential drawbacks of using CAI therapies in the treatment
of PTSD, there are important reasons to consider this category of interven-
tions as part of a treatment plan for PTSD. First, the current patient-­centered
care focus in health care obliges providers to respond to client preferences,
and CAI interventions are well utilized and gaining popularity (NCCIH,
2018b). Surveys indicate that 20% of those diagnosed with PTSD (Bystritsky
et al., 2012) and approximately half of U.S. veterans and military personnel
use CAI modalities to address symptoms such as stress and chronic pain and
to promote relaxation and well-being (Libby, Pilver, & Desai, 2013; Taylor et
al., 2019). Second, CAI interventions are freely available in many settings.
They are frequently offered and promoted in health care systems, commu-
nity organizations, or workplace wellness programs as part of larger preven-
tive health promotion efforts, often at little to no cost to the individual. For
example, the Veterans Health Administration (VHA), the largest integrated
health care system in the United States, offers CAI health services “such
as acupuncture, mind-body techniques, yoga, and massage” at many of its
1,250 health care facilities as part of a strategic goal to “empower veterans
to improve their well-being” (U.S. Department of Veterans Affairs, 2016).
Third, there are few drawbacks to many of the treatments that fall under the
category of CAI: side effects are frequently absent or positive (i.e., improved
strength and fitness, enhanced sense of well-being), and client satisfaction
ratings are generally high. Therefore, in many clinical settings it is reason-
able to encourage these adjunctive treatments as part of the treatment plan
for individuals with PTSD who seek them.
Complementary, Alternative, and Integrative Interventions 355

Treatment planning can be challenging when clients with PTSD request

CAI treatments in place of psychotherapies with more robust empirical
evidence to support them. It is recommended that clinicians always begin
treatment planning discussions by communicating the evidence available to
support various treatment options. Based on that shared understanding, pro-
viders can then collaboratively move toward treatment planning, considering
client preferences and previous experiences. Establishing measurable goals
is equally important when considering CAI interventions as with traditional
interventions; providers should not persist with treatments that show little
measurable benefit and should use shared goals as a way to encourage explo-
ration of approaches that were not initially preferred. In this way, CAI treat-
ments may be a “foot in the door” to facilitate future engagement in evidence-­
based psychotherapies or other treatment if the CAI does not provide the
desired effects. By developing a positive alliance with a provider or health care
system and fostering discussion of holistic goals, engaging in CAI interven-
tions may increase openness to considering other treatment modalities.
For both individual clinicians and health-­ care systems, determining
the quality and legitimacy of available treatments is one of the biggest chal-
lenges. We know to be wary of nostrums; expensive, heavily advertised inter-
ventions that claim to cure all ills in a short amount of time are likely to
disappoint. There is emerging evidence provided by this review to support
several approaches, but definitive guidance is lacking. If the treatments cited
here are unavailable, it can be difficult to determine how to guide clients in
choosing. Clinicians can look to other mental health research to evaluate the
legitimacy of interventions that may be offered to their clients. Some CAI
interventions have solid empirical bases for disorders that are frequently
comorbid with PTSD, such as depression, chronic pain, or management of
physical disorders. If the research has been conducted by a variety of objec-
tive researchers who do not have strong interests in the success of a particu-
lar intervention, this offers additional confidence that claims of the interven-
tion’s success are not exaggerated. In such cases, we reiterate the importance
of maintaining an evidence-­based stance: establish mutually agreed-­upon,
measurable goals to be reevaluated according to a set schedule. If goals are
met, continue course and speed. If not, engage in collaborative discussion of
which untested approaches would be a next reasonable step.

Characteristics of CAI Interventions to Consider

Group versus Individual
Some PTSD clients seek treatment groups with people who have had similar
traumatic experiences, while socially avoidant clients may steadfastly refuse
any group program. Group interventions can be very helpful in ameliorating
isolation and depression that commonly accompany PTSD, and therapists
should encourage clients to consider the added benefits of participating in
356 Treatments for Adults

CAI therapies with others. At this time, the literature on CAI cannot sup-
port one modality over another.

Treatment Targets and Individual Preferences

One strategy that clinicians may adopt could be to match strategies to indi-
vidual symptom profiles; meditative therapies may be preferable for those
with high hyperarousal symptoms, whereas group exercise may provide
interaction for those who are isolative or activation for those with concurrent
low mood/low energy. Individuals who have participated in sports in their
youth and veterans who engaged in physical training in the military also
may find a group exercise intervention immediately appealing. Although the
CAI interventions included in these guidelines are largely secular, some CAI
treatments have spiritual components that may either augment or conflict
with religious practices. Clients with a background in martial arts may be
drawn to tai chi, a form of martial arts composed of slow, gentle movements,
or those who have played an instrument may be drawn to music therapy.
Anecdotal reports of success experiences with CAI therapies, from public
figures in the media or friends and relatives, may inspire individuals to try
certain treatments. Such factors reasonably may be incorporated in treat-
ment planning given the importance of client preference in outcomes and
the lack of data to guide individual treatment matching.

Instructor Match
Information about the expertise, personality, and “match” of a specific
instructor also may be utilized in choosing an intervention. A compelling,
dynamic instructor can draw in and motivate hesitant individuals. Many CAI
programs have certification and training criteria for teachers, so certified
instructors should be sought to support client safety. For example, yoga teach-
ers have 200-, 300-, or 500-hour yoga therapist certifications, so clinicians
should familiarize themselves with the training and experience of providers
in their area. Instructors should be cognizant of the need for some modifica-
tions in their procedures to accommodate individuals with PTSD, such as sug-
gesting to individuals with high levels of vigilance that they may prefer to keep
their eyes half open during a meditation, or using verbal cues rather than
manual adjustments to guide proper body positions in yoga or tai chi. As an
example, Emerson, Sharma, Chaudhry, and Turner (2009) have described a
set of trauma-­sensitive modifications for yoga practice. As noted before, how-
ever, providers should use caution that modifications do not foster avoidance.

Practical and Logistical Considerations

Aspects of accessibility are predictive of follow-­through with exercise pro-
grams (e.g., Morgan et al., 2016). Thus, practical concerns for individuals,
Complementary, Alternative, and Integrative Interventions 357

such as financial costs, distance to travel, access to public transportation, or

availability of parking, and whether the environment is welcoming should
be weighted in decision making. Practical considerations are relevant for
health care systems also, as interventions such as yoga that require large,
empty spaces may not be feasible in some settings and specialized equipment
such as treadmills or acupuncture tables may not be available or affordable.
On the other hand, many CAI interventions are delivered in groups and
do not require special equipment or large spaces, making them less finan-
cially burdensome to facilities. There are also online or app-based delivery
options for some of these techniques; clinicians should consider compiling a
resource list if there is sufficient demand within their practice. In weighing
the costs and benefits for a health care system, the costs are often low. Even
if the benefit of a particular approach is not yet established, it may be useful
to consider other potential benefits for health care systems, such as respond-
ing to patient preferences, promoting a positive image to the community,
and promoting wellness broadly. Ultimately, satisfaction with a health care
system should be driven not only by a reduction in target symptoms but also
by improved functioning and quality of life.

Resources for Maintenance

At the end of a 10-week yoga program or a 12-session meditation course, cli-
ents may have difficulty continuing to practice on their own. It is important
to incorporate relapse prevention strategies from the outset and to encour-
age clients to access resources that will assist them with home practice both
during and following the intervention. Online videos and/or smartphone
applications can augment between-­session practice during the intervention
and increase the likelihood that individuals will continue to utilize these
resources after the intervention ends. Local resources, such as yoga classes
at a neighborhood gym or drop-in meditation groups, have the potential to
provide a supportive community to encourage a new practice to develop into
a lifestyle routine; again, it can be helpful to clinicians to maintain lists of
good options.

Active versus Passive

Given the heterogeneity of the therapies considered to be CAI, one useful
classification in CAI treatments is the extent to which they are “active” versus
“passive.” In active therapies, instructors teach skills in session that clients
are encouraged to practice and hone on their own outside of sessions. These
treatments require agency from clients as they are expected to initiate home
practice, to use the skills taught as they live their lives outside of session,
and to maintain these skills beyond the termination of the formal sessions.
Examples include yoga, meditation, and physical exercise, which typically
can be delivered in group settings with minimal need for equipment. They
358 Treatments for Adults

often have resources available (i.e., written materials, audio or video record-
ings, links to smartphone applications) to facilitate practice outside of ses-
sions. Benefits of active approaches therefore may include a sense of agency
for the client and low-cost barriers for the provider or health care system.
By contrast, in therapies such as acupuncture or massage, clients pas-
sively receive the treatment as they are delivered one-on-one from a thera-
pist. In addition, specialized equipment (e.g., acupuncture needles, massage
table) may be required. Thus, passive techniques can create some risk of
dependence on the provider or external attribution of change. Passive treat-
ments also may not be financially feasible as ongoing, long-term practices
for clients. To avoid such pitfalls, these therapies may best be applied in the
short term to “ jump start” additional lifestyle changes and cognitive shifts
to sustain positive effects. Passive treatments also may allow reluctant par-
ticipants to experience benefits without a great deal of initial effort, thereby
generating hope for clients that their symptoms can improve or there is suf-
ficient symptom relief to allow engagement in other approaches.
Figure 19.1 provides tips for the application of CAI therapies in the
treatment of PTSD.

Future Developments

The current evidence for CAIs is limited; none of the approaches have more
than emerging evidence to support them. Interest is high in this area, how-
ever, leading to the hope that future guidelines will be able to provide more
definitive recommendations. Along with potentially leading to important
advancements in recovery from PTSD, CAIs also bring new scientific chal-
lenges. The outcomes of CAI interventions are often expected to be broader

1. Employ evidence-based practices, including objective assessment of outcomes.

2. Help clients to make informed choices, set objective markers of success, and plan
to revisit progress.
3. Identify and use high-quality strategies that have been used before (e.g., existing
classes, apps) and that are inexpensive or in the public domain, rather than
inventing or recommending untested yet expensive products.
4. Coordinate with other providers to consider the total burden for the client and to
consider any unintended effects (e.g., fostering avoidance).
5. Only deliver interventions directly with proper training and supervision.
6. Encourage open-minded exploration: a client may try a variety of techniques to
determine the best match in terms of sustainability and response.
7. Plan for posttreatment maintenance of new practices.

FIGURE 19.1. Tips for application of CAI therapies in the treatment of PTSD.
Complementary, Alternative, and Integrative Interventions 359

than a reduction in PTSD symptoms, so investigators should determine the

best ways to assess recovery in a more holistic way. Broader outcome assess-
ment will benefit consumers of PTSD treatment more broadly because all
interventions share the goal of restoring optimal functioning.
With a seemingly endless number of approaches and numerous vari-
ants within each approach, we risk stalling advances in care for the sake
of evaluating every approach. We encourage reductionist strategies: iden-
tify and apply key change agents (e.g., nonreactivity to internal experience,
focused attention, reduced arousal) that are shared by multiple approaches.
In this way, we may develop thoughtfully integrated care, although we will
be left with the challenge of developing methodologies to evaluate person-
alized approaches and outcomes. Ultimately, this process may lead to the
development of empirically based integrated programs, an elusive entity at
this juncture.
To the extent that protocols are developed, this should be done with
adequate specificity to allow for replication (e.g., meditation protocols, pre-
scribed acupuncture points) and clear criteria for training and certifying
instructors/providers. Within a given approach, studies will be necessary
to determine optimal dose and timing. Although this process may seem
antithetical to CAI providers who are accustomed to individually tailor-
ing treatments, it is critical to building an evidence base to guide care. In
some instances, an approach may not lend itself to manualization. Examples
include exercise and yoga, which are taught in thousands of venues and are
available online. In such cases, it may be more useful to develop guidelines
(e.g., types of exercise or supporting instructions) to guide consumers to
apply the practice to their recovery.
In spite of the nontraditional nature of some of the interventions, meth-
odologically rigorous studies should be strongly encouraged, which is a call
for the research community to support such endeavors. Studies should be
appropriate to the level of evidence about the approach (NCCIH, 2017c).
RCTs should include equally appealing, active control conditions. Research-
ers should use common data elements so that results can be compared across
studies. Longer-­term outcome assessment will be necessary to assess durabil-
ity of change and whether maintenance of practice is critical to durability
of improvements. We may need to borrow from colleagues who are experts
in studying lifestyle change for health outcomes to apply the techniques to
supporting long-term mental wellness.

Summary

Complementary, alternative, and integrative practices describe a set of

intervention techniques that are not currently part of traditional Western
practice. Although highly utilized worldwide for amelioration of physical
and mental health problems, evidence of their efficacy for the treatment of
360 Treatments for Adults

PTSD is just emerging. This chapter describes four approaches with emerg-
ing evidence—­yoga, acupuncture, SKK, and somatic experiencing—­as well as
others that may be promising, such as certain types of meditation, for which
there is not yet sufficient support to make a recommendation. Although
not recommended as first-line PTSD interventions, their high degree of
safety and demonstrated benefits in other areas (e.g., stress reduction, pain,
physical wellness) lead us to encourage their thoughtful use to complement
standard care within an evidence-­based framework. We strongly encourage
additional empirical evaluation of CAI interventions.

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C H A P TE R 2 0

Treatment of Complex PTSD

Marylene Cloitre, Thanos Karatzias, and Julian D. Ford

C omplex posttraumatic stress disorder (CPTSD) was formally recognized

as a mental disorder with the release of the 11th revision of the Interna-
tional Classification of Diseases (ICD-11; World Health Organization, 2018).
CPTSD is listed under the parent category “disorders specifically associated
with stress” (code 6B41), and diagnosis requires traumatic exposure and at
least one symptom from each of six clusters. The first three, shared with
posttraumatic stress disorder (PTSD), are reexperiencing in the here and
now, avoidance of traumatic reminders, and a sense of current threat. The
second three clusters, reflecting “disturbances in self-­organization” (DSO),
are affective dysregulation, negative self-­concept, and difficulties in forming
and maintaining interpersonal relationships. CPTSD also requires that the
PTSD and DSO symptoms cause significant impairment in functioning.
CPTSD represents the spectrum of problems that follow from traumatic
exposures that are typically of a chronic and repeated nature, particularly,
but not exclusively, interpersonal trauma during the developmental years of
childhood and adolescence. Unlike previous formulations of the concept of
complex PTSD, however, type of trauma is a risk factor not a requirement,
for consideration of the CPTSD diagnosis. This recognizes the presence
of personal (e.g., genetic or dispositional) and environmental (e.g., social
support or lack thereof) factors that can create increased risk for or pro-
tection against the disorder. For example, a person who has experienced
sustained childhood sexual abuse might develop PTSD rather than CPTSD,
or might not develop any trauma-­related disorder, depending on disposi-
tional strengths and the presence of protective resources, such as caregivers
who have effectively safeguarded development. Alternatively, an individual
who experiences a single traumatic event in adulthood (e.g., witnessing
the murder of his or her child) might develop CPTSD given dispositional

365
366 Treatments for Adults

vulnerabilities, poor social support, a nonresponsive or negative social envi-

ronment, or a history of adverse childhood events.
As CPTSD is a new disorder, no studies have as yet been reported that
directly test the effectiveness of psychological therapies or pharmacothera-
pies for ICD-11 CPTSD. In the absence of published treatment studies, the
Guidelines Committee of the International Society for Traumatic Stress
Studies (ISTSS) identified a range of CPTSD treatment options for inves-
tigation, including current evidence-­based PTSD therapies, interventions
derived from cognitive, behavioral, mindfulness, emotion regulation, psy-
chodynamic, interpersonal, pharmacological, or technology-­based formula-
tions and combination or sequential therapies incorporating these interven-
tions (ISTSS Guidelines Committee, 2018). This chapter presents broadly
framed treatment recommendations consistent with the guidelines and sup-
ported by published studies that have included the assessment and treat-
ment of individuals with histories of chronic exposure to multiple types of
interpersonal trauma. This chapter provides basic principles for therapeutic
work with adults with CPTSD and empirically informed best practices in the
assessment and treatment of ICD-11 CPTSD. The CPTSD diagnosis is appli-
cable to children and adolescents as well, and the treatment of CPTSD in
these samples is addressed by Berliner, Meiser-­Stedman, and Danese (Chap-
ter 5, this volume).

Therapeutic Frame

Treatment of CPTSD begins with the establishment of a therapeutic frame

by obtaining a fully informed consent for participation from the patient fol-
lowing a collaborative discussion of his or her rights, the procedures that will
be involved, the potential outcomes and limitations of treatment, and the
responsibilities of the therapist. Although this introduction is a requirement
in all forms of psychological and medical treatment, it has special signifi-
cance with persons with complex trauma histories that may have involved
sustained victimization, deception, exploitation, or betrayal by trusted oth-
ers (Courtois & Ford, 2013).
A fundamental principle guiding both the assessment and treatment
of individuals with CPTSD is the assumption that many of the symptoms
resulting from sustained and multiple forms of interpersonal trauma begin
as adaptive efforts under conditions of extreme adversity. Dissociation and
emotional numbing are protective reactions to overwhelming experiences.
Avoidance of relationships and intimacy can be strategies for staying physi-
cally and emotionally safe. Mistrust and aggressive behaviors such as those
that occur in combat or in environments of chronic violence (e.g., multi-
generational civil war) are necessary for survival. These reactions transition
from adaptive to nonadaptive when the traumatic threats no longer are
present but the affective, cognitive, and behavioral adaptations continue,
Treatment of Complex PTSD 367

creating a mismatch between an environment and responses to it. Alterna-

tively, some traumatic exposures continue for extended periods of time (e.g.,
warfare, domestic violence, community violence) and overtax the individual
such that repertoires for managing trauma and stress convert into less flex-
ible and less adaptive responses (chronic dissociation, learned helplessness).
Psychoeducation is an important component of the theoretical frame
for treatment. This includes explaining how CPTSD symptoms develop as
adaptive responses to a traumatic event, with the goal of normalizing the
patient’s experience of his or her symptoms and reducing stigma. During
the assessment and throughout all phases of the treatment process, the ther-
apist instills hope by describing how the treatment will address the specific
problems that the patient is presenting, by identifying the specific personal
and relational resources the patient is bringing to the treatment, and by
describing the collaborative nature of decision making in the therapy. The
therapist listens carefully and without assumptions about which problems
bother the patient most and respects that individual’s interests and pref-
erences. Emphasis on the collaborative nature of the work, responsiveness
to the patient’s concerns, and flexibility in implementing the treatment all
support the therapeutic alliance, which has been consistently demonstrated
as a significant contributor to engaging, retaining, and achieving positive
outcomes with adults with a wide range of psychosocial problems.

Tasks of Treatment

Three important tasks of treatment are identified in this section and include
assessment, treatment planning and implementation, and follow-­up care or
supportive reintegration of the patient into his or her community and life
activities (see Courtois & Ford, 2013).

1. Assessment. Creating an appropriate treatment plan includes assess-

ing the life circumstances of the patient with regard to safety and stability
and conducting a good differential diagnosis, particularly between CPTSD
and borderline personality disorder (BPD). Individuals with CPTSD who
are living in chaotic and disruptive conditions (e.g., ongoing domestic vio-
lence, homelessness) should be provided services that address their needs
for safety and stability as a first step, and such services must be maintained
as needed throughout the course of treatment. For patients who are not
currently exposed but are at risk for exposure to violence or victimization,
the development and maintenance of a safety plan will be integral to the
treatment.
2. Treatment planning and implementation. Consistent with the definition
of CPTSD, treatment focuses on resolution of both PTSD and DSO symp-
toms. The goal of treatment includes reducing intrusive reexperiencing and
368 Treatments for Adults

avoidance of trauma memories and the associated sense of fear and inescap-
able threat that represent the PTSD symptoms, while also increasing the
core self-­competencies of affect regulation, interpersonal skills and security,
and positive self-­concept.
3. Follow-­up care and reintegration. Due to the chronicity and severity of
their traumas as well as their symptoms, individuals with CPTSD may have
become disconnected from or never participated in family or community
life, have limited social support and few relationships, and have limited edu-
cation or employment prospects. Common underlying factors driving these
circumstances are a sense of being somehow “damaged” or “different” from
members of the surrounding community, fear of being stigmatized, or hav-
ing actually been stigmatized due to their trauma and significant limitations
or a deterioration in their functional capacities related to relationships,
social engagement, and work.

Follow-­up care can include continued contact with patients via “booster”
sessions and the opportunity to return to treatment during times of stress.
Additional resources can be recommended, such as support groups with
other survivors to address stigma and increase their sense of community,
and where they can share resources to support education, employment,
housing, health care, parenting, and addiction recovery. These resources
encourage and help maintain a sense of normality, efficacy, and social con-
nectedness that patients might have never experienced in the past, and offer
an opportunity to develop a sense of purpose in life and to commit to life
goals and objectives.

Assessment

Assessment of CPTSD includes the evaluation of CPTSD symptoms as well

as associated biopsychosocial symptoms (e.g., suicidality, self-harm, addic-
tions, guilt, shame, sexuality, sleep), adverse life circumstances and stress-
ors, and personal and relational resources and strengths. Comorbidity and
co-­occurring stressors or adversities are common in CPTSD; hence, these
are important to identify using empirically validated measures.
In adult patient populations, special attention is given to the differential
diagnosis of CPTSD as compared to BPD. At least four studies have demon-
strated that CPTSD and BPD are distinct disorders, with distinct symptom
profiles and patient populations (see Hyland, Karatzias, Shevlin, & Cloitre,
2019). BPD and CPTSD have conceptual overlap in the type of problems
that are included in each diagnosis, namely, difficulties in affect regulation,
self-­concept, and interpersonal relationships. However, there are important
phenomenological differences in how these symptoms manifest across the
disorders.
Treatment of Complex PTSD 369

CPTSD and BPD are most similar in the domains of affect disturbances
of emotional reactivity and numbing. However, in addition and central to
the BPD diagnosis is the presence of suicide attempts and self-­injurious
behavior, which are priority targets in treatment. Individuals with CPTSD
may have a history of suicide attempts and self-­injurious behaviors, but this
is not central to their presentation and indeed is not part of the diagnosis.
In BPD, self-­concept difficulties reflect an unstable sense of self, whereas in
CPTSD, it reflects a persistent, negative view of the self. Relational difficul-
ties in BPD are characterized by volatile patterns of interactions, whereas in
CPTSD, they reflect a persistent tendency to avoid relationships. There are
other relevant features that differentiate BPD and CPTSD, most notably the
fact that CPTSD requires the presence of trauma-­specific PTSD symptoms
and BPD does not require traumatic exposure for diagnosis. A diagnosis of
BPD can be made via several validated measures currently available. At this
time, there are two reliable and validated measures to assess CPTSD. One is
a brief self-­report measure, the International Trauma Questionnaire (ITQ;
Cloitre et al., 2018), and the other an interview, the International Trauma
Interview (ITI; Roberts, Cloitre, Bisson, & Brewin, 2018).

Treatment Approach
Commitment to Best Practices
CPTSD is a new diagnosis, and there is to date no direct evidence about how
to treat it. ISTSS guidelines, consistent with those of several other profes-
sional societies (e.g., American Psychological Association, 2017), recommend
that the decision for how to treat a particular individual with a particular
disorder follow from the available empirical evidence as well as several other
considerations, including the patient’s values and preferences, individual
differences (cultural values, previous successes and failures in treatment),
and the clinician’s expertise. All four factors—­empirical evidence, patient
preferences, individual differences, and clinician expertise—­a re applied to
develop a treatment plan that has the highest likelihood of achieving the
identified goals of therapy. This three-­factor approach, particularly atten-
tion to patient needs and preferences, is especially important when empiri-
cal evidence is limited.

Evidence from Meta‑Analyses

Karatzias and colleagues (2019) and Coventry (2018) conducted meta-­
analyses to identify whether current evidence-­based therapies for PTSD were
equally appropriate for patient populations that were representative of those
who might meet criteria for the newly established CPTSD diagnosis. In both
meta-­analyses, the authors identified randomized controlled trials (RCTs)
for PTSD that included (1) samples that had experienced sustained exposure
370 Treatments for Adults

to interpersonal trauma (e.g., childhood abuse, domestic violence, combat,

genocide campaigns) and (2) measures corresponding to the CPTSD symp-
tom clusters related to the PTSD factor (reexperiencing, avoidance, and
heightened sense of threat) and to the DSO factor (emotion dysregulation,
negative self-­concept, and interpersonal difficulties).
Karatzias and colleagues (2019) found that trauma-­focused therapies
were effective in reducing symptoms in all six CPTSD domains. However,
moderator analyses determined that the trauma-­focused therapies were con-
sistently less positive for persons with histories of childhood trauma com-
pared to those who had experienced trauma only in adulthood, and this was
true for each of the six CPTSD symptom clusters. The Coventry (2018) meta-­
analysis found that both trauma-­focused and non-­trauma-­focused therapies
provided substantial benefits for PTSD symptoms but noted that the positive
effects for the DSO symptom clusters were modest. There was some sug-
gestion that multicomponent therapies provided a better outcome, particu-
larly among childhood sexual abuse survivors. In sum, the results of these
meta-­analyses suggest that current therapies for PTSD are not likely to be
optimal for CPTSD patient populations and that one strategy for improving
outcomes is a multimodular approach.
A multimodular approach that is made up of empirically supported
interventions is consistent with, and supports use of, the treatment guide-
lines. Multimodular approaches provide flexibility with regard to the selec-
tion and implementation of interventions so that they can be organized to be
responsive to the presenting problems, needs, and preferences of patients.
This approach takes advantage of the availability of validated trauma mem-
ory processing (TMP) therapies to treat symptoms of the PTSD cluster (such
as reexperiencing, nightmares, and avoidance) but also allows consideration
of interventions that focus on emotion regulation (ER), identity issues, or
relationship problems. There are a variety of ways multiinterventions or
multimodal interventions can be implemented, including sequenced (phase-
based), combination, or integrative strategies. Examples of therapies that
implement each of these strategies are provided later in the chapter.

Important Symptoms of CPTSD to Target

CPTSD is by definition a relatively complex disorder, and it is not necessar-

ily the case that all symptoms or symptom clusters are of equal importance.
Identification of the symptoms that are central to the disorder and have
the most influence in exacerbating or maintaining other symptoms provides
guidance on how to conceptualize the goals of treatment.
A recent network analysis of CPTSD symptoms in four nationally rep-
resentative samples (Knefel et al., 2019) found that negative self-­concept was
the most central aspect of the CPTSD formulation, followed by affect dysreg-
ulation. Negative self-­concept has been defined in terms of persistent beliefs
Treatment of Complex PTSD 371

about one’s self as diminished, defeated, or worthless, accompanied by deep

and pervasive feelings of shame, guilt, or failure. The network analyses indi-
cated that interpersonal problems were related to emotion regulation (ER)
difficulties (particularly numbing) and negative self-­concept (Knefel et al.,
2019), suggesting these as the most complex and potentially challenging
problems to resolve. The PTSD symptoms were less central to the disorder
and significantly influenced by the DSO symptoms. To address the limited
information about, and past attention to, how best to treat DSO symptoms,
several empirically supported interventions that directly target each of the
three DSO clusters are presented next.

Negative Self‑Concept
“Third-wave” cognitive-­behavioral therapies focus on exercising mindful-
ness or developing a more compassionate attitude toward one’s self for the
purposes of ameliorating psychological distress by changing the client’s rela-
tionship to his or her problems. Mindfulness approaches may be effective
for the treatment of CPTSD per se as there is some evidence that mindful-
ness can reduce avoidance and enable ER, symptoms of the PTSD and DSO
cluster, respectively (see Banks, Newman, & Saleem, 2015; Follette, Palm, &
Pearson, 2006).
However, of most relevance to the problem of negative self-­concept
are interventions that focus on the development of self-­compassion. Self-­
compassion has been described as involving three distinct elements, includ-
ing (1) being kind and understanding toward oneself in times of difficulty,
(2) being mindfully aware of painful thoughts and feelings to prevent over­
identification, and (3) seeing one’s struggles as part of a broader human
experience rather than as a unique and isolating experience (Neff, 2011).
Thus, self-­compassion can be particularly helpful with symptoms of nega-
tive self-­concept and disrupted relations by reducing self-­judgment, rumina-
tion, and feelings of isolation (Gilbert & Irons, 2004). For example, Karatzias
and colleagues (2018) found direct relationships between dimensions of self-­
compassion and CPTSD symptoms; specifically, self-­judgment and isolation
significantly predicted negative self-­concept, while self-­judgment and com-
mon humanity significantly predicted hypoactive affect dysregulation. These
data suggest that adding compassion-­based interventions to the treatment of
CPTSD might be particularly useful for symptoms of disrupted sense of self.

Emotion Regulation Difficulties

In light of the salient role of affect dysregulation in CPTSD, systematic inter-
ventions to enhance ER are a logical component of treatment. Two therapies
are provided as example interventions. They are relatively brief and have
been tested with complex trauma populations and shown to reduce ER prob-
lems and interpersonal difficulties.
372 Treatments for Adults

Trauma Affect Regulation: Guide for Education and Therapy (TAR-

GET) is a 4- to 20-session treatment that has been implemented with diverse
trauma populations in several studies (Ford, 2020b). As relevant to adults
with CPTSD, a 10-session version of the treatment was found to be effec-
tive in reducing ER and interpersonal problems as well as PTSD symptoms
when evaluated among low-­income mothers with extensive histories of mul-
tiple forms of victimization beginning in childhood and chronic PTSD, as
compared to a present-­centered interpersonal therapy (IPT) or treatment
as usual (TAU; Ford, Steinberg, & Zhang, 2011). The treatment teaches a
seven-step sequence of self-­regulation skills summarized by the acronym
FREEDOM. The first two skills, Focusing and Recognizing triggers, provide
a foundation for shifting from stress reactions driven by hypervigilance to
proactive ER. The following four skills provide a dual-­processing approach
to differentiating stress-­related and core value-­g rounded Emotions, Evalua-
tive thoughts, client-Defined goals, and behavioral Options. The final skill
is designed to promote application of the skills set in everyday life as well as
enhance self-­esteem and self-­efficacy by purposeful allocation of attention
to recognizing how being emotionally regulated when experiencing stress-
ors (including reminders of past traumatic events and intrusive memories) is
a way to Make an important positive contribution in relationships, at school/
work, and in the pursuit of personal goals. The results suggest that although
the treatment focused heavily on ER difficulties, it provided positive signifi-
cant benefits to the remainder of the DSO and PTSD symptoms.
Skills Training in Affect and Interpersonal Regulation (STAIR) is a
brief (5- to 12-session) treatment that can be used in individual or group
format and has been applied to different types of trauma populations. As
relevant to adults, the efficacy of 5-session STAIR as a stand-alone treat-
ment has been evaluated in an RCT of veterans with diverse traumas and,
as compared to wait list, was found to improve ER, interpersonal, and social
engagement strategies and to reduce PTSD symptoms (Jain et al., in press).
More relevant to “complex trauma,” an open trial of a 10-session version of
the treatment delivered via tele-­mental health to women veterans with mili-
tary sexual trauma and high rates of childhood abuse was found to improve
the same symptom sets. The treatment provides psychoeducation on the
impact of trauma on ER and relationships, followed by successive sessions
on ER (emotional awareness, ER, distress tolerance, and positive activities)
and concluding with interpersonal skills training. The interpersonal work
includes recognizing and modifying maladaptive expectations in relation-
ships as well as improving communication skills to enhance assertiveness,
interpersonal flexibility, and closeness with others.

Interpersonal Difficulties
STAIR directly addresses interpersonal difficulties, and both STAIR and
TARGET have demonstrated effectiveness in reducing interpersonal diffi-
culties and improving social functioning. However, IPT is entirely dedicated
Treatment of Complex PTSD 373

to interpersonal difficulties. IPT is a 14- to 16-week treatment that focuses

on four areas of interpersonal difficulties: interpersonal disputes, role tran-
sitions, grief/loss or interpersonal sensitivity, and social deficits. Although
IPT has not been tested with a complex trauma population in individual
format, it has been tested in group format among women with PTSD who
had experienced multiple interpersonal traumas (Krupnick et al., 2008).
An RCT found that compared to wait list, the group treatment provided
superior reductions in interpersonal problems as well as PTSD symptoms.
Additionally, a 14-session version of IPT delivered as individual therapy was
compared to prolonged exposure (PE) and relaxation therapy (RT) among
those with PTSD related to various types of trauma. IPT was found to yield
comparably positive results overall for adults diagnosed with PTSD and
lower dropouts for the entire sample; for the subgroup who had histories
of chronic sexual assault, however, IPT was superior to both PE and RT
(Markowitz, Neria, Lovell, Van Meter, & Petkova, 2017). While not directly
assessing CPTSD, this study further suggests that IPT may be beneficial for
adults with complex trauma histories and symptoms.

Summary
This review has highlighted the relative centrality of the DSO symptoms
in the CPTSD diagnosis and described several interventions that success-
fully address them. A further important question is how to organize selected
interventions into a program of treatment.

Treatment Delivery: Ordering Interventions

Flexible Problem‑Focused Multimodular Approach
The flexible problem-­ focused treatment model sequences treatment by
addressing symptoms based on priorities collaboratively identified by the
patient and therapist. The use of flexible, problem-­driven multimodular
interventions has been shown to be highly effective and superior to single
module treatments in mental health services for children and adolescents
(Weisz et al., 2012). This approach is particularly useful for patients who
have moderate to high heterogeneity in symptom presentation, as is true
with CPTSD.

Sequential Multimodular Treatment

Sequential treatments are protocols that deliver treatment modules ordered
in a set fashion. Patients and therapists may select particular interventions
within each treatment component, but the components themselves are fixed.
Sequential treatments for CPTSD have traditionally used three sequential
components: first, interventions to ensure safety and enhance personal,
social, and environmental resources and self-­regulation capacities; second,
374 Treatments for Adults

interventions for TMP; and third, interventions for generalizing therapeutic

gains to daily life (Courtois & Ford, 2013). Four RCT studies of sequential
treatments have been reported. All four studies enrolled women who had
experienced significant interpersonal trauma and had either a diagnosis of
PTSD related to childhood abuse or BPD and PTSD. The studies varied in
outcomes of interest, but all studies indicated that this approach provided
benefit to patients.
An RCT of a two-­module treatment, STAIR followed by narrative ther-
apy (derived from PE), was conducted among women with PTSD related to
childhood abuse and found that compared to wait list, the treatment pro-
vided significant and superior improvements in ER, social support, interper-
sonal functioning, and PTSD symptoms (Cloitre, Koenen, Cohen, & Han,
2002). Moreover, improvements in ER and the quality of the therapeutic
alliance established during STAIR facilitated effective use of the narrative
work as measured by PTSD symptom reduction, providing a rationale for
this treatment order. A second RCT compared the sequential treatment to
two comparator conditions, each of which tested one active component by
replacing the partner component with supportive counseling. Results indi-
cated that the STAIR/narrative therapy combination provided superior out-
comes as compared to the other two conditions (Cloitre et al., 2010). This
finding suggests the particular benefits of specific interventions tailored to
ER and interpersonal disturbances.
The two other RCTs enrolled women with BPD plus PTSD, and the
treatments involved the sequencing of dialectical behavioral therapy preced-
ing trauma-­focused work. A pilot RCT by Harned and colleagues (Harned,
Korslund, & Linehan, 2014) reported that women assigned to DBT plus
PE compared to DBT alone showed better outcomes in PTSD symptoms as
well as reduced suicide attempts and self-­injury, the latter two being key tar-
gets of BPD treatment. The introduction of the exposure work was flexible
and initiated, on average, 24 weeks into the treatment, contingent on the
patient’s ability to achieve high-­priority treatment targets (emotional self-­
control, no suicide or self-­injurious behaviors for 2 months). In a recently
completed RCT, Bohus (2018) compared DBT plus CPT as compared to
CPT alone. In the CPT-alone treatment, trauma-­focused work was initiated
at about the 15th week of treatment, while the DBT plus CPT treatment
started TMP at approximately 24 weeks. Both treatments were of equal
duration (approximately 1 year). Findings indicated superior outcomes on
measures of PTSD as well as important outcomes of ER, beliefs about self,
and interpersonal/social engagement in the sequenced treatment as com-
pared to CPT alone.
There has been some concern that sequencing treatments where the
trauma-­focused work comes after other treatment modules may result in
adverse effects, specifically in reinforcing avoidance of TMP or undermin-
ing the patient’s confidence in mastery over traumatic material (De Jongh et
al., 2016). However, no evidence supports this concern. Indeed, the data thus
far indicate that treatment dropout and symptom exacerbation are reduced
Treatment of Complex PTSD 375

when treatments are sequenced with skills-­training interventions preceding

TMP (Cloitre et al., 2010).
Sequential treatments have the benefit of limiting the amount of new
learning and behavioral practice that occurs at any one time, in contrast to
combination treatments where the presence of multiple interventions pre-
sented simultaneously may create a burden in the assimilation of new infor-
mation and practice of new behaviors. Nevertheless, requiring a particular
sequencing structure may be inconsistent with the principle of “patient-­
centered” care. For example, reversing the order described previously—that
is, TMP first—may be clinically appropriate and of greater therapeutic value
for some patients. Examples include situations where patients wish to imme-
diately address their trauma memories, patients whose most salient symp-
toms are nightmares or reexperiencing (including flashbacks), or whose
avoidance of trauma-­related stimuli significantly impairs daily functioning
(e.g., cannot drive a car or travel to their work location).
Investigations evaluating which sequences work best and for whom are
an important next step in research. Similarly, it would be of interest to con-
duct comparative effectiveness trials assessing the benefits of patient-­driven
compared to protocol- or algorithm-­determined approaches in sequencing
interventions.

Combination Treatments
Combination treatments refer to those where multiple intervention com-
ponents are delivered relatively simultaneously over a period of time. This
approach is often used and relatively easily implemented in residential or
inpatient settings. An open trial of a DBT-PTSD program was tested in a
residential treatment setting for women who had PTSD related to childhood
sexual abuse (Steil, Dyer, Priebe, Kleindienst, & Bohus, 2011). The treatment
comprised several groups (skills training, self-­ esteem, mindfulness, and
PTSD psychoeducation) as well as two weekly 35-minute individual therapy
sessions, about a quarter of which were dedicated to exposure techniques.
The duration of the treatment across the participants was approximately 3
months; treatment outcomes indicated significant reductions in PTSD as
well as depression and anxiety. The treatment did not assess changes in ER,
negative self-­concept, or interpersonal functioning.
Another example of a combination approach is Concurrent Treatment
of PTSD and Substance Use Disorders Using Prolonged Exposure (COPE).
The treatment has been evaluated in an RCT where it was compared to
relapse prevention therapy (RPT) and an active monitoring control group
(AMCG) in a sample of adults with PTSD and a co-­occurring substance use
disorder (SUD) (Ruglass et al., 2017). Results indicated that COPE and RPT
were superior to AMCG for PTSD and SUD symptom reduction, and COPE
was superior to RPT in PTSD symptom reduction for persons with a full
PTSD diagnosis. The organization of the treatment was innovative: different
components were layered one on top of the other across time. The 13-session
376 Treatments for Adults

treatment began with 4 sessions devoted to enhancing motivation and CBT

for SUD; in vivo exposure was incorporated in Sessions 5–12, imaginal expo-
sure in Sessions 6–12, and CBT for PTSD in Sessions 8–12, with a review
and aftercare program in the 13th session. The treatment did not evaluate
psychiatric or psychosocial symptoms other than PTSD and did not iden-
tify patients who might have had CPTSD. However, the treatment model
presents an interesting “layering” strategy for introducing interventions that
may be useful for CPTSD where treatment components have some overlap-
ping goals (e.g., improvement in ER, then using ER skills to facilitate TMP
and to improve interpersonal and social skills).

Group Therapy

Group therapies are a practical way to provide interventions to large numbers

of patients and can have a number of benefits for CPTSD sufferers. Group
therapies might be particularly useful for treating the relationship/interper-
sonal problems of CPTSD by enabling participants to exercise existing skills
or acquire new interpersonal skills by participating in a group that promotes
safety, respect, honesty, and privacy (Karatzias, Ferguson, Gullone, & Cos-
grove, 2016). By being in a group of individuals who share similar experiences
but are at different stages of recovery, group therapy can instill hope that
recovery is possible. Group therapies can also provide opportunities for inter-
personal learning (e.g., effective communication, the difference between safe
and supportive vs. victimizing or exploitive relationships) that patients who
have lived in chronically traumatizing environments may not have had the
opportunity to experience. Therapeutic group interactions also can provide
opportunities to observe how others are able to modulate and recover from
negative emotional states, and to safely experience positive emotions that may
have been prohibited or punished in past traumatic experiences.
There are several group therapy models that may be applicable to
CPTSD. These include cognitive-­behavioral therapy (CBT)—with or without
TMP—ER, IPT, as well as psychodynamic, feminist, and relational/support-
ive therapeutic approaches. TMP in group therapy may be implemented
using a CBT approach, as an intensive first-­person or narrative retelling of a
specific trauma memory with or without cognitive restructuring, or in a rela-
tional and testimonial manner in which a group member describes the past
and current impact that such traumatic events had, and continue to have,
on his or her life, including emotions, self-­concept, relationships, achieve-
ments, self-­defined failures or disappointments, and view of the future
(Ford, 2020a).
A recent meta-­analysis identified 36 RCT studies of group therapy: 10
studies with TMP group therapies and 26 with trauma-­focused group thera-
pies that did not involve TMP (Mahoney, Karatzias, & Hutton, 2019). Partici-
pants were predominantly women with histories of childhood abuse or vio-
lence at the hands of an intimate partner. Trauma-­focused group therapies
Treatment of Complex PTSD 377

achieved greater improvements in PTSD symptoms than wait-list controls or

TAU but were not superior to active non-­trauma-­focused group therapies.
The trauma-­focused group therapies had comparable benefits in improving
PTSD and dissociation symptoms regardless of whether TMP was included.
However, trauma-­ focused group therapy yielded the best outcomes for
depression and psychological distress if TMP was not included. Thus, psy-
choeducation and skills for affect and interpersonal regulation may be of
particular value in group therapy for adults with CPTSD.
The effectiveness of phased interventions offered in a group format for
adults with CPTSD-like trauma histories and symptoms also was examined
in meta-­analysis (Mahoney et al., 2019). Phase 1 (delivered first) psychoeduca-
tional interventions were associated with reductions in symptoms of general
distress (e.g., anxiety and depression), whereas Phase 2 (delivered second)
memory processing group interventions were associated with reductions
in PTSD symptoms. Thus, interventions representing both phases in the
sequential treatment paradigm can be useful for the treatment of CPTSD.
Research evaluating the relative efficacy of differently ordered treatment
components and whether specific sequences may be of particular benefit to
certain types of patients is important for optimizing outcomes.

Treatment Challenges
Development of a Treatment Plan
Treatment planning for CPTSD involves identification of the specific forms
of dysregulation of emotion, relationships, and sense of self that are causing
impairment and are of primary concern to the individual patient. Therefore,
a collaborative attitude toward the patient as a partner in identifying the key
treatment problems and selection of evidence-­based intervention, as well as
a measurement-­based approach assessing change over time in the primary
goals of the patient’s therapy, is essential to guiding treatment. Regular
assessment will help determine how well target problems in each domain
of CPTSD are resolving and importantly whether new problems are emerg-
ing, in order to update the treatment plan as therapy proceeds. Given the
complexity of CPTSD, and the variable presentation with different patients,
the formulation and updating of a correspondingly complex and individual-
ized treatment plan that accounts for all significant CPTSD symptoms and
impairments is essential in order to fully address the needs in each unique
case.

Length of Treatment
Length of treatment is likely to be highly variable depending on the sever-
ity, number, and diversity of clients’ symptoms, the strengths and skills they
bring to the therapy, the specific goals of treatment, and the emergence
of crises that disrupt treatment. Many clients achieve substantial symptom
378 Treatments for Adults

reduction and other gains within a few months. However, more extended
involvement of a year or beyond followed by periodic check-ins (particularly
if stressors lead to symptom exacerbation or recurrence) is likely to be benefi-
cial, enabling the client to make fundamental and enduring changes in core
beliefs, relational choices and working models, coping and goal-­attainment
styles, and ER and crisis prevention/management skills.

Tempo of Treatment
Establishing a steady tempo of sustained therapeutic work is often difficult.
Clients with CPTSD are likely to live with high levels of fear, anxiety, shame,
and dysphoria that interfere with self-­reflection and learning and with apply-
ing new skills and knowledge. It is important to choose a tempo that matches
the client’s capacity for learning and to engage in a deliberate pace that
neither pushes for overly rapid results nor slows to a standstill due to fear,
dysphoria, or other emotional or interpersonal problems. Helping the client
to make steady progress even when crises or “stuck points” occur provides
a corrective learning experience that represents an important contrast with
previous life experiences (e.g., failure or relapse into old behaviors). Engag-
ing in what may seem to be small talk or listening with interest while the
client talks about current or past events provides essential basic human con-
tact that often has been missing in his or her experiences and can open the
door to spontaneous disclosures by the client, thus offering opportunities
for empathic reflection and teaching by the therapist.

Maintaining Focus While Adjusting the Tasks of Treatment

It is important to maintain a coherent treatment focus based on the treatment
plan, while also flexibly moving between the two primary tasks of CPTSD
treatment: processing memories of past traumas and dealing with current
stressors or life activities. Past-­focused (processing of trauma) and present-­
focused (dealing with daily life stressors) interventions are complementary
rather than competing tasks that together help clients become aware of and
able to actively process (rather than avoid) trauma reminders and trauma-­
related emotions, thoughts, and behavior patterns. Both of these therapeu-
tic tasks typically may need to be repeated over time, potentially causing the
therapy to occasionally appear to be “going backward,” to enable clients to
consolidate and sustain their gains going forward in treatment and in life.

Severe Dissociation
Severe dissociation can lead to great discomfort for the therapist as well
as the client. A proactive approach to working with dissociation is to help
the client recognize triggers for dissociation and proactively use ER skills
and a growing trust in relationships (initially the therapeutic relationship
Treatment of Complex PTSD 379

and gradually other relationships) to either interrupt or transition out of

dissociative states. A key therapeutic task therefore is to assist the client
in developing reflective self-­awareness and confidence in recognizing and
managing the distress that leads to dissociation. Interventions helpful in
the management of dissociation include body self-­awareness and grounding
as well as enhancement of the client’s understanding of why dissociation
occurs and how to process rather than avoid distressing emotions, thoughts,
and impulses. If a diagnosis of dissociative identity disorder (DID) is present,
the therapist should focus on validating the client’s experience of distinct
self-­states while maintaining the perspective that the client is a single self
with multiple aspects. Consultation with or referral to a clinician with spe-
cialized training in treating DID and other severe and sustained forms of
dissociation is recommended in such cases.

Concurrent Problems and Team Work

Clients with CPTSD may present with co-­occurring health problems, includ-
ing physical injuries from traumatic exposures (e.g., combat, sexual assault)
and chronic health disorders (e.g., chronic pain, gynecological disturbances,
heart or gastrointestinal disorders). These types of problems are best treated
through collaboration with trauma-­informed health care specialists in other
disciplines, where an integrated treatment plan is developed and tracked
over time, potentially including the use and management of medications
for both mental and physical health problems. Individuals with CPTSD may
have several providers for different diagnoses, and there is thus a risk of
treatment becoming “siloed” and the client experiencing what seem to be
contradictory or conflicting treatment plans. The presence of providers
from primary care or other disciplines should be explicitly highlighted as
part of all treatment plans, both in discussions with clients and in the final
reports of treatment outcomes. In addition, there may be a potential role
or need for the mental health clinician to provide respectful and sensitive
education to other providers involved in the client’s care, including primary
health providers, concerning the client’s possible cues and triggers, attitudes
and concerns (e.g., distrust of authority figures), and symptoms (e.g., disso-
ciation, reduced attentional capacities) that will facilitate collaborative and
effective management of the client’s multiple health problems.

Crises and Chaotic Lives

Individuals with CPTSD may experience a substantial number of crises and
ongoing exposure to major life stressors, including traumatic events such as
domestic violence, accidents, new illnesses and diagnoses, and family mem-
bers in crisis, injured, or dying. Although crises cannot always be antici-
pated, the therapist can help the client to identify stressor events and resul-
tant reactions that are likely and may be anticipated or coped with using
380 Treatments for Adults

skills learned in treatment and support from healthy relationships. Applying

treatment concepts and skills to proactively anticipate and constructively
debrief crisis or symptom escalation episodes can help clients increase their
confidence and sense of competence or mastery. In addition, the clinician
can help the client develop a network of services that are readily accessible.

Role of the Therapeutic Alliance

Clinician awareness of the beneficial role of the therapeutic alliance can
facilitate progress and consolidate gains, while lack of attention to the thera-
peutic alliance can hinder or undermine progress. The therapeutic alliance
is an important foundation for coregulation between therapist and client,
and for helping the client to move from coregulation to self-­regulation and
mutuality rather than dependence or avoidance in relationships (Courtois
& Ford, 2013). It also can enable clients to safely process reexperiencing or
reenactments of the trauma-­related dynamics of past victimization, betrayal,
or other interpersonal traumas, providing the client with role modeling and
guidance in the exploration of painful emotions and memories with confi-
dence and self-­compassion. Lastly, clients can learn from the therapist via
role modeling of various skills, such as authentic self-­regulation, acknowl-
edgment of mistakes and misunderstandings, and maintaining professional
limits within a therapeutically boundaried relationship.

Conclusion

The development and clinical and scientific evaluation of best practices and
replicable therapeutic interventions for adults with CPTSD are nascent.
However, innovative treatment models, and approaches to the sequenc-
ing and delivery of treatment, for this challenging clinical population are
emerging and show promise in empirical studies. The codification of a
CPTSD diagnosis in ICD-11 provides a much-­needed foundation for system-
atic treatment development and randomized clinical trial studies that will
guide therapists and patients as they collaboratively develop and implement
treatment designed to promote recovery from the combination of PTSD and
disturbances of self-­organization that constitute CPTSD.

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PA R T V

TREATMENTS FOR CHILDREN

AND ADOLESCENTS
C H A P TE R 21

Treatment of PTSD and Complex PTSD

Tine Jensen, Judith Cohen, Lisa Jaycox, and Rita Rosner

Tlogical
his chapter covers recommendations for the treatment of posttraumatic
stress disorder (PTSD) in children and adolescents including pharmaco-
interventions. We review the summary of evidence and provide a
theoretical basis for understanding change processes in child trauma treat-
ment. A review of common elements across treatments and developmental
considerations are highlighted, as well as treatments for different settings
such as school and war-torn countries. Lastly, clinical guidelines for work-
ing with complex PTSD (CPTSD), newly identified as a disorder in the 11th
revision of the International Classification of Diseases (ICD-11), are discussed
along with recommendations for future research.

Summary of the Evidence

As reviewed in Forbes, Bisson, Monson, and Berliner (Chapter 1, this vol-

ume), the scoping questions for children were slightly modified from scop-
ing questions for adults due to fewer studies and to acknowledge differences
between children and adults affected by trauma. The scoping question was
the following: For children and adolescents with clinically relevant posttrau-
matic stress symptoms, do psychological treatments when compared to treat-
ment as usual, waiting list, no treatment, or other psychological treatments
result in a clinically important reduction of symptoms, improved function-
ing/quality of life, presence of disorder, or adverse effects? For pharma-
cological interventions, the scoping question was this: For children and
adolescents with clinically relevant posttraumatic stress symptoms, do phar-
macological treatments when compared to placebo, other pharmacological,
or psychosocial interventions result in a clinically important reduction of

385
386 Treatments for Children and Adolescents

symptoms, improved functioning/quality of life, presence of disorder, or

adverse effects?
The recommendations are thus based on studies that explicitly tar-
get PTSD and significant posttraumatic stress symptoms as the primary
outcome(s). It is nonetheless recognized that other outcomes may be just
as important for children and adolescents, such as depression, anxiety, dis-
ruptive and externalizing behaviors, substance abuse, and school function-
ing. Within this framework, a Strong recommendation has been given to
cognitive-­behavioral therapy with a trauma focus (CBT-T), provided either
alone with the child or with the child and caregiver. There was Insufficient
Evidence to Recommend CBT-T only with the caregiver. Eye movement desen-
sitization and reprocessing (EMDR) therapy also received a Strong recom-
mendation. The work group decided to include an Intervention with Emerging
Evidence category to recognize novel treatment approaches. These recom-
mendations were usually based on one or two randomized controlled trials
(RCTs) with lower-­quality ratings. Although such interventions are not rec-
ommended as frontline approaches for the treatment of PTSD, there may
be other considerations that warrant their use. For example, although group
CBT-T with children is classified as an Intervention with Emerging Evidence, it
may be a very helpful treatment to make available to reach children who may
not otherwise receive services, especially in low- and middle-­income coun-
tries. It is also noteworthy that of all the treatment interventions reviewed
for children and adolescents, none received an Insufficient Evidence to Recom-
mend rating. This means that there are many different interventions that
may prove helpful and many promising new ones.
This chapter focuses on recommended treatments and their common
elements.

Cognitive‑Behavioral Models of PTSD

Most of the recommended interventions in the guidelines issued by the

International Society for Traumatic Stress Studies (ISTSS) are based on
cognitive-­behavioral theory (CBT), which has provided a primary theoreti-
cal foundation for understanding trauma impact and serves as the basis for
trauma-­focused interventions (TF-CBT; Brewin, Dalgleish, & Joseph, 1996;
Ehlers & Clark, 2000). CBT is based on the idea that thoughts, feelings, and
behaviors are interconnected and mutually influence each other, and that
targeting thoughts, feelings, and/or behavior in therapy can bring about
positive change. Although initially developed for adults, several scholars
have argued that the same theoretical approach can be used to explain and
understand the development of posttraumatic responses in children and
youth (Ehlers, Mayou, & Bryant, 2003; Hayes et al., 2017; Meiser-­Stedman,
2002; Meiser-­Stedman, Dalgleish, Smith, Yule, & Glucksman, 2007; Salmond
et al., 2011).
Treatment of PTSD and Complex PTSD 387

In particular, the cognitive theory proposed by Ehlers and Clark (2000)

has been applied in the child trauma field (Meiser-­Stedman, 2002; Smith,
Perrin, Yule, & Clark, 2010). According to this model, two processes are cen-
tral in the development and maintenance of PTSD: (1) disturbances in the
memory processing of the traumatic event(s) and (2) negative appraisals and
interpretations of the trauma and/or its sequelae that often become global
and overgeneralized. According to this theory, PTSD becomes persistent if
the traumatic memories are poorly elaborated and contextualized and are
not well integrated with other autobiographical memories. Due to impaired
processing and storing of the traumatic memories, the memories remain
in a sensory format. Consequently, trauma reminders (e.g., trauma-­related
cues or stimuli reminding the child of the trauma) can easily trigger these
memories. Trauma reminders may evoke intense psychological and physi-
ological reactivity and arousal, leading to distress and unpleasant emotions
(Cohen, Mannarino, Deblinger, & Berliner, 2009). Disturbance in the mem-
ory processing of the trauma can thus explain the intrusive and involuntary
characteristics of trauma memories, resulting in increased activation, avoid-
ance, intrusive symptoms, and reexperiencing (Brewin et al., 1996; Ehlers &
Clark, 2000; Foa & Rothbaum, 2001).
The other central aspect of Ehlers and Clark’s model is related to how
negative appraisals of the trauma and/or thoughts and reactions in the after-
math of trauma affect an individual’s beliefs about his or her self and the
world. When experiencing one or more terrifying and overwhelming events,
children search for an explanation or reason for why such an event happened
to them. This is often an attempt to gain and restore some sense of control or
predictability in life. However, if no rational explanation can be found, they
may develop inaccurate and dysfunctional beliefs and cognitions to make the
world predictable and understandable once again. Thus, traumatic experi-
ences may profoundly change the way children see themselves and the world,
and trauma-­related cognitions often become global and overgeneralized. Such
negative and maladaptive cognitions are commonly observed among trauma-
tized children and youth (Meiser-­Stedman et al., 2009; Nixon et al., 2010).
Negative posttraumatic cognitions can threaten an individual’s view of the
self (e.g., “I must be a bad person since these things keep happening to me”)
and the world (e.g., “Something bad can happen at any time”; “No one can
be trusted”), causing a subjective sense of persistent and current threat, and
encourage the use of maladaptive coping strategies (Meiser-­Stedman et al.,
2009). Inaccurate and dysfunctional cognitions and beliefs about causation
and responsibility might also result in feelings of shame and guilt, helpless-
ness and hopelessness. A child who struggles with these emotions will likely
have thoughts of being worthless and damaged, leading to depression and
increasing the risk for withdrawal, isolation, and interpersonal and behavioral
problems (Cohen, Mannarino, & Deblinger, 2017). Thus, posttraumatic cog-
nitions can contribute to the development and maintenance of posttraumatic
stress symptoms, but also lead to depression and anxiety (Beck, 2005).
388 Treatments for Children and Adolescents

Behavioral aspects of the development of PTSD focus on the way that

avoidance of trauma memories and trauma reminders produces an immedi-
ate reduction in distress, and therefore is reinforced over time (via negative
reinforcement). Such avoidance can reinforce the negative appraisals as well
as create limitations in daily functioning.
Thus, global and overgeneralized trauma-­related appraisals and behav-
iors may explain many of the characteristics of persistent PTSD, such as
perception of current threat, avoidance, symptoms of arousal, negative emo-
tions, and lack of trust in others. These experiences often lead to a range
of coping strategies that may be maladaptive and contribute to the mainte-
nance of PTSD (Bryant, Salmon, Sinclair, & Davidson, 2007; Ehlers et al.,
2003; Meiser-­Stedman et al., 2007; Mitchell, Brennan, Curran, Hanna, &
Dyer, 2017; Stallard & Smith, 2007).

Possible Change Processes in Child Trauma Treatment

There is emerging evidence that cognitive processes are important in not
only the development and maintenance of posttraumatic stress reactions
in youth, but also for treatment outcomes. Several youth studies have now
demonstrated that changing cognitions is an important mechanism for
reducing posttraumatic stress symptoms in treatment (Jensen, Holt, Mørup
Ormhaug, Fjermestad, & Wentzel-­Larsen, 2018; Meiser-­Stedman et al., 2017;
Pfeiffer, Sachser, de Haan, Tutus, & Goldbeck, 2017; Smith et al., 2007). For
instance, Meiser-­Stedman and colleagues (2017) found in one RCT compar-
ing CBT-T to wait list that changes in posttraumatic cognitions mediated
the beneficial effects of CBT-T on posttraumatic stress symptoms among
children and adolescents exposed to a single-­event trauma. This is in line
with two other treatment studies that found evidence for the same cognitive
mediation effect on posttraumatic stress symptoms in TF-CBT for multi-
traumatized youth (Jensen et al., 2018; Pfeiffer et al., 2017). It is, however,
still unclear whether reductions in posttraumatic stress early in treatment
contribute to more adaptive and helpful cognitions, or if cognitive changes
precede the reduction in posttraumatic stress. To date, only two published
studies have examined the longitudinal directional relationship between
changes in posttraumatic cognitions and posttraumatic stress symptoms in
a clinical sample of traumatized youth, with both showing that changes in
cognitions precede changes in posttraumatic stress (Knutsen, Czajkowski,
& Ormhaug, 2018; McLean, Yeh, Rosenfield, & Foa, 2015). Taken together,
these studies indicate that changing maladaptive cognitions in traumatized
youth should be a primary target of treatment. What the mechanisms of
change are is still unclear, and it may be that several components or tech-
niques contribute to altering cognitions. For instance, providing psychoedu-
cation and using Socratic methods can alter negative or unhelpful thoughts.
Teaching coping skills when facing trauma reminders and trauma exposure
work may reduce a sense of ongoing threat, and the belief that the world is
Treatment of PTSD and Complex PTSD 389

a dangerous place. Having new positive personal experiences may alter feel-
ings of mistrust in adults.
In a series of studies, Hayes and colleagues sought to understand more
about the change processes in TF-CBT by examining the role of overgen-
eralizations, rumination, and avoidance in the processing of traumatic
experiences in youth. They found that more overgeneralization during
the narrative phase predicted less improvement in internalizing symptoms
at posttreatment and a worsening of externalizing symptoms at follow-­up
(Ready et al., 2015). Overgeneralization was associated with more rumi-
nation, less decentering, and more negative emotion (Hayes et al., 2017).
Interestingly, they did not find that changes in these cognitive processes
were related to a decrease in posttraumatic stress symptoms for these youth.
Thus, more studies are needed to fully understand such complicated change
processes.
A central element in all treatment is engaging the youth in the ther-
apy process. The therapeutic alliance predicts treatment outcomes in child
and adolescent therapy (Murphy & Hutton, 2018), but is less explored in
child trauma treatment studies. Some studies have, however, determined
that a strong therapeutic alliance is related to trauma treatment outcomes
(­Ormhaug, Jensen, Wentzel-­ Larsen, & Shirk, 2014; Zorzella, Muller, &
­Cribbie, 2015). One study examining the therapeutic alliance in TF-CBT
and therapy as usual (TAU) found that the alliance predicted outcome in
TF-CBT but not TAU. Since treatment outcomes were significantly higher
in TF-CBT, this indicates that both a good alliance and trauma focus are
necessary for good outcomes (Ormhaug et al., 2014). Also, rapport-­building
behaviors in early sessions of TF-CBT are associated with a stronger alliance,
and having a focus on trauma experiences does not appear to undermine
alliance formation, but rather facilitates the alliance with youth who are pas-
sively disengaged (Ovenstad, Ormhaug, Shirk, & Jensen, 2020).

Developmental Considerations in Treatment

Developmental considerations should always play a role in the treatment of

children and adolescents. However, what may be a common, appropriate,
and “normal” behavior in early childhood might be regarded as abnormal
in adolescence. Boundaries are usually not sharply defined for developmen-
tal stages and determining what is abnormal needs to factor in age, gen-
der, developmental stage, and societal and cultural norms at a minimum.
Younger children may show less specific symptoms. Development may come
to a rest in specific areas so that children may be judged as younger or not
adequately developed for their age.
Age-­specific reactions to traumatic events are known, including sepa-
ration anxiety, temper tantrums, and enuresis for toddlers and preschool
children, while school-­age children may display oppositional behavior or
390 Treatments for Children and Adolescents

stress-­reactive somatic complaints. Recent research shows that type and tim-
ing of traumatic events in childhood and adolescence may affect the severity
of not only PTSD but also of other (comorbid) syndromes, such as major
depression, substance abuse, and anxiety disorders (for a review, see Teicher
& Samson, 2016). This points to possible underlying neurodevelopmental
processes and epigenetic modifications. Psychosocial development and all
its components such as emotion regulation, personality development, attach-
ment, morality, and many more may be affected negatively by early trauma.
Diagnostic considerations are discussed in other chapters of this book
(see Berliner, Meiser-­Stedman, & Danese, Chapter 5, and Cloitre, Cohen,
& Schnyder, Chapter 23). In addition to diagnostics, developmental con-
siderations are vital in treatment planning. The most relevant aspects are
(1) whether and how much parents and caregivers should be included, (2)
dosage, and (3) the adaptation of interventions in a developmentally appro-
priate way.
For children under 3 years, interventions might be almost exclusively
directed at caregivers (i.e., parent–­child relationship enhancement); in pre-
school and school-­age children, an equal distribution of time for parents
and children is advisable, that is, TF-CBT (Cohen, Deblinger, & Mannarino,
2016) and preschool PTSD treatment (PPT; Scheeringa, 2015). Interventions
for adolescents and young adults include parents and caregivers significantly
less or not at all (Foa, McLean, Capaldi, & Rosenfield, 2013; Rosner et al.,
2019). This reflects the adolescents’ need to become more independent and
autonomous, while at the same time parents and caretakers are still legally
responsible.
In terms of dosage, younger children may need shorter sessions, whereas
the session length for adolescents is often the same as for adults. Thus, the
amount of time spent with the caregiver may be adapted to the child’s devel-
opmental age. Also, interventions for preschoolers should include more
childlike modes of interventions such as playing, storytelling, and drawing,
whereas interventions for teenagers can be more language-­driven. In addi-
tion, treatment for adolescents should consider specific developmental tasks
in this age group, for example, autonomy, romantic relationships, or career
choices.
Finally, and in terms of the evidence base, although most of the child-
and adolescent-­specific manuals are adapted to developmental age, empiri-
cal comparisons of developmentally adapted manuals with not adapted
manuals do not exist, thus leaving these developmental considerations on
the level of clinical recommendations.
Yet, there is some empirical support stemming from previous meta-­
analyses (Gutermann et al., 2016; Morina, Koerssen, & Pollet, 2016) that
do report age effects. Depending on the analysis subset (e.g., when look-
ing at RCTs only), Gutermann and colleagues (2016) determined that older
children benefit more than younger children in terms of posttraumatic
Treatment of PTSD and Complex PTSD 391

symptom severity reduction. Similarly, Morina and colleagues (2016) found

a correlation between age and treatment efficacy (only for comparisons with
wait lists). But the median age in both meta-­analyses was around 12 years,
and only a handful of studies on preschoolers as well as adolescents (above
14 years of age) were included. Thus, these age groups are underrepresented
in the two meta-­analyses and the age-­related findings are only valid for a
very restricted age range.

Common Elements
across Recommended Treatments

The majority of trauma treatments with empirical support for improving

posttraumatic stress and PTSD are CBT-based models. In part, this may be
the case because CBT-based approaches generally use and are guided by
standardized assessments, are easy to systematically describe in a treatment
manual, and are easy to replicate across treatment settings with clearly estab-
lished standards of fidelity. Thus, CBT-based models readily meet require-
ments for use in RCTs for many childhood disorders.
Treatments based on CBT typically include certain common elements:
psychoeducation, various types of coping skills, cognitive restructuring for
unhelpful thoughts, and behavioral components (e.g., exposure for anxiety;
behavioral activation or problem solving for depression; contingency man-
agement for disruptive behavior). Different CBT models may sequence the
delivery of the common elements in different ways and emphasize some ele-
ments more than others.
Some core underlying CBT principles as related to trauma-­ focused
treatment include the following:

1. Thoughts, feelings, and behaviors are interconnected: untrue/

unhelpful trauma-­ related beliefs (self-blame, dangerous world, untrust-
worthy others) lead to negative emotional states and/or unhelpful behav-
iors. The unhelpful behaviors may have a legitimate function (e.g., relief,
reduction of distress, avoidance of perceived danger), but can interfere with
recovery and functioning.
2. Trauma avoidance is a hallmark of posttraumatic stress and PTSD
and interferes with recovery and functioning. Common CBT components
address and reduce avoidance (e.g., psychoeducation, coping skills, expo-
sure, and cognitive processing).
3. Behavior has a purpose and typically functions to get a desired
result or avoid a negative outcome. Behavior is influenced by antecedents
and consequences (A → B → C); positive or negative reinforcement will
serve to perpetuate the behavior even when the behavior is unhelpful or
392 Treatments for Children and Adolescents

not functional. Behaviors such as avoidance, withdrawal, reactivity, or act-

ing out may arise in children affected by trauma because they bring relief,
reduce risk for rejection, or lead to needed attention even if negative. Ante-
cedents to traumatized children’s traumatic behavioral problems are often
trauma reminders (e.g., a loud voice, perceived rejection, parental scolding
for misbehavior). The consequences may inadvertently reinforce the unhelp-
ful behaviors. For example, parents may allow children to not go to school
or make exceptions about behavioral expectations as a form of being sup-
portive for trauma impact. But this may lead to functional problems and
parent–­child conflict. Effective CBT strategies, especially positive parenting
techniques, can modify these child traumatic behavioral problems.

The common elements found in most of the recommended models and

their application to trauma impact are listed next.

Psychoeducation
The goal of psychoeducation is to empower children and their families to
understand more about posttraumatic reactions (i.e., make sense of their
symptoms), and to become a collaborative partner in treatment. Psychoedu-
cation provides information about posttraumatic stress and PTSD and the
prevalence of trauma, and stresses that recovery is possible. Through psy-
choeducation, youth learn to connect their symptoms to their trauma expe-
riences rather than to think there is something inherently wrong with them
(e.g. “I’m bad”; “I’m crazy”). All trauma-­focused child trauma treatments
include some form of psychoeducation to explain, validate, and normalize.

Coping Skills
Many models typically include teaching a variety of coping skills (relaxation,
controlled breathing, emotion identification and monitoring, cognitive cop-
ing, distraction, mindfulness, and positive parenting) to address the youth’s
physical, emotional, cognitive, and behavioral dysregulation. Trauma-­
specific child models often encourage youth to not only use these skills for
everyday stressors, but also to apply them in response to trauma-­specific
cues (trauma reminders), and in therapy to prepare for the exposure and
restructuring activities that may evoke distress as well as in vivo. The goal of
coping skills in trauma-­specific therapy is to forestall avoidance and teach
mastery. Children learn to regulate negative trauma-­related emotions and
behaviors by recognizing feelings and changing maladaptive beliefs. Differ-
ent trauma models emphasize teaching coping skills to a greater or lesser
degree. The evidence does not show that extensive coping skills practice is
always necessary before directly addressing the trauma and, in some cases,
it can prolong avoidance of the imaginal exposure and restructuring com-
ponents. Teaching coping skills in itself without further trauma-­related work
Treatment of PTSD and Complex PTSD 393

does not seem to be efficient for reducing posttraumatic stress in adults, but
the child literature has not yet examined this issue.
One big challenge for teaching coping skills is that they are typically
taught in the low-­stress, supportive environment of a clinic office. Many cli-
ents can demonstrate proficiency of a skill in that context, especially with
modeling and role-play practice. However, the key is to focus on the success-
ful use of coping skills in real-life stressful contexts whether they are trauma-­
related or not. The focus on between-­session practice is often essential for
the acquisition of coping skills that may be used effectively in real life.

Exposure and Cognitive Restructuring

The goals of exposure and cognitive restructuring for traumatized youth are
to master trauma avoidance, fear, and other negative trauma-­related symp-
toms by directly confronting feared trauma memories and nondangerous
trauma reminders, and to identify and correct trauma-­related maladaptive
cognitions. Techniques include trauma narration in different forms. As with
adult approaches, many models for children differentially emphasize ima-
ginal/in vivo exposure and cognitive processing. For example, prolonged
exposure (PE) adapted for adolescent sexual assault victims primarily uses
exposure (Foa et al., 2013). In EMDR therapy, imaginal exposure is used by
asking the youth to internally remember his or her worst traumatic experi-
ence without describing or recording it aloud. Other models incorporate
both exposure and processing through creating a written narrative of the
youth’s trauma “story” (e.g., TF-CBT, Cognitive-­ Behavioral Intervention
for Trauma in Schools [CBITS]) or use a life narrative or timeline utilizing
stones to represent traumas and flowers to represent positive experiences
(e.g., KidNET). In each of these models, therapists work with youth to iden-
tify and correct trauma-­related maladaptive cognitions.

Parenting Support and Skills

Most child interventions incorporate parents in the treatment. There are
several potential goals and benefits of incorporating an active parenting
component into treatment for traumatized youth. Parental involvement
can enhance their understanding of the youth’s trauma experiences and
increase emotional support for the youth. Engaging parents may facilitate
treatment through reinforcement and support in practicing the skills in real
life that are taught during therapy. Inclusion of effective parent manage-
ment training may be especially important for youth exhibiting traumatic
behavior problems, which can lead to negative parent–­child interactions,
reduced emotional support for the child, and functional impairment (e.g.,
school or community problems).
Not all of the recommended treatments fully integrate parents into
treatment. Recommendations are listed in Table 21.1.
394 Treatments for Children and Adolescents

TABLE 21.1. Recommendations for Psychological Treatment

Strong Recommendation—CBT-T (caregiver and child), CBT-T (child), and EMDR therapy are
recommended for the treatment of children and adolescents with clinically relevant
posttraumatic stress symptoms.
Intervention with Emerging Evidence—Group CBT-T (child), group psychoeducation, and
parent–child relationship enhancement have emerging evidence of efficacy for the
treatment of children and adolescents with clinically relevant posttraumatic stress
symptoms.
Insufficient Evidence to Recommend—There is insufficient evidence to recommend
CBT-T (caregiver), family therapy, group CBT-T (caregiver and child), KidNET, nondirective
counseling, or stepped-care CBT-T (caregiver and child) for the treatment of children and
adolescents with clinically relevant posttraumatic stress symptoms.

Strongly Recommended Treatments

Trauma‑Focused Cognitive‑Behavioral Therapy
TF-CBT (Cohen et al., 2017) has the most RCT studies for effectively treating
child and adolescent posttraumatic stress and PTSD as well as related trauma
symptoms. To date, 20 RCTs of TF-CBT have been published (reviewed in
Cohen et al., 2017, pp. 74–80). These studies have focused on different index
traumas—for example, sexual abuse, domestic violence, commercial sexual
exploitation, war, disaster, and diverse traumas—although as is typical, most
children in TF-CBT treatment studies have experienced multiple traumas
(e.g., Cohen, Deblinger, Mannarino, & Steer, 2004; Cohen, Mannarino, &
Iyengar, 2011; Goldbeck, Muche, Sachser, Tutus, & Rosner, 2016; Jensen et
al., 2014; O’Callaghan, McMullen, Shannon, Rafferty, & Black, 2013). TF-
CBT studies have been conducted for youth across development, in diverse
settings and across different countries and cultures (e.g., in the United States,
Europe, Australia, Africa), and have been provided in individual and group
formats. These studies have consistently documented the efficacy of TF-CBT
in improving children’s posttraumatic stress and PTSD, with multiple stud-
ies also showing the superiority of TF-CBT to comparison or control condi-
tions for improving children’s anxiety, depression, externalizing behavior
problems, and/or trauma-­related maladaptive cognitions. Additionally, TF-
CBT has been shown to be superior to comparison conditions for improv-
ing participating parents’ support of the child, parental emotional distress,
parental PTSD symptoms, and effective parenting practices.
TF-CBT is CBT-based; the core principles include (1) a structured, com-
ponents- and phase-based approach with defined pacing of components; (2)
collaborative empiricism and an assessment-­driven approach in which the
therapist, youth, and parent monitor the youth’s trauma and other relevant
symptoms throughout treatment and adjust the implementation of TF-CBT
components accordingly; (3) gradual exposure incorporated into all com-
ponents to enhance the youth’s and parent’s mastery of trauma reminders;
Treatment of PTSD and Complex PTSD 395

and (4) parent or caregiver inclusion throughout treatment to support the

youth’s practice and mastery of skills, enhance positive parenting and paren-
tal support, address trauma-­related behavior problems, improve the parent’s
understanding of trauma impact, and minimize parental emotional distress
related to the youth’s trauma experiences (Cohen et al., 2017). TF-CBT con-
sists of individual sessions provided in parallel to youth and parent, with half
of each treatment session provided to the youth and parent, respectively,
with several joint child–­parent sessions also included in the model. Treat-
ment duration is 12–16 sessions (this may be extended to 16–24 sessions for
more complex trauma situations).
The core components of TF-CBT are summarized by the acronym
PRACTICE and include the following: psychoeducation, parenting skills,
relaxation skills, affective regulation skills, cognitive processing skills,
trauma narration and processing, in vivo mastery (the only TF-CBT optional
component, reserved for youth who have overgeneralized fear and avoidance
of safe situations), conjoint child–­parent sessions, and enhancing safety and
future developmental trajectory. TF-CBT also includes traumatic grief com-
ponents, described in detail at www.musc.edu/ctg.

Preschool PTSD Treatment

PPT (Scheeringa, 2015) is a CBT-based model that includes all of the PRAC-
TICE components described above. It differs from TF-CBT for preschoolers
in that (1) this model is more highly structured following a session-­by-­session
format; (2) the parent views the child’s sessions behind a one-way mirror
to better understand and support the child’s trauma responses; (3) treat-
ment addresses one identified primary trauma experience, rather than the
full range of experienced traumas; and (4) there is relatively more focus on
fear desensitization than on cognitive processing. One RCT (Scheeringa,
Weems, Cohen, Amaya-­Jackson, & Guthrie, 2011) documented significant
efficacy of the model in improving preschool children’s PTSD symptoms
relative to a comparison condition.

Cognitive Therapy for PTSD

Cognitive therapy for PTSD (CT-PTSD; Smith et al., 2010) shares many of
the same features as TF-CBT and is based on Ehlers and Clark’s (2000)
cognitive model of PTSD and their treatment program for adults (Ehlers,
Clark, Hackmann, McManus, & Fennell, 2005). Two studies have shown the
model to have good effects on children who have experienced single-­event
traumas (Meiser-­Stedman et al., 2017; Smith et al., 2007). CT-PTSD empha-
sizes an integration of cognitive restructuring with reliving. The protocol
differs from TF-CBT in that it typically does not include relaxation training
or other arousal reduction techniques for decreasing stress. The use of in
vivo exposure is more common, and changing unhelpful cognitions is highly
396 Treatments for Children and Adolescents

emphasized as the hallmark of this model. Sessions are typically conducted

with the child alone. Parents are often included to review interventions from
the child sessions and to plan homework tasks. The treatment targets are (1)
elaborating and developing the trauma memory into a coherent account, (2)
identifying problematic appraisals of the trauma and its consequences, (3)
helping the child to not use unhelpful cognitive and behavioral strategies.
The treatment components include the following:

1. Psychoeducation. The child and usually the parents are provided with
information about PTSD and the cognitive model. The child’s symptoms are
reviewed, and the child is helped to identify unhelpful strategies he or she
has been using.
2. Reclaiming your life. The child and parents are asked to identify activi-
ties that give the child a sense of fun, social connectedness, and meaning that
he or she may have dropped after the trauma. The child is encouraged, with
support from the parents, to identify and return to normal activities.
3. Imaginal reliving. The child is guided through an imaginal reliving
to help access the moments in the trauma memory that are linked to the
problematic meanings of the trauma without using any form of relaxation
or anxiety management strategies. If the child becomes upset, the therapist
provides empathy and encourages the child to talk about his or her feelings
and normalizes these. The child is asked to talk about the trauma from its
beginning until the point when the child felt safe again. The primary focus is
to identify areas of confusion and/or emotional “hot spots.” These are then
specifically targeted.
4. Cognitive restructuring. The therapist helps the child identify idiosyn-
cratic appraisals about the trauma and/or the child’s reactions.
5. Updating the trauma memory. Hotspots in the narrative are often
accompanied by appraisals about feared outcomes. The therapist discusses
hotspots with the child and helps the child to identify alternative and more
functional appraisals that are then incorporated into the reliving. The child
is asked to include the new information in the trauma narrative by speak-
ing it out loud during imaginal reliving of the hotspot or writing it into the
relevant spot in the narrative script.
6. Working with triggers (stimulus discrimination). The therapist and child
work together to identify stimuli that trigger unwanted intrusions. The child
is then encouraged to confront these triggers and make a conscious effort
to focus on everything about the present that is different from the memory
while remaining aware of the present. This is done initially in-­session and
then practiced as homework.
7. Site visit. A visit to where the trauma happened is used to help the
child understand that the trauma is over. The child is asked to remind
Treatment of PTSD and Complex PTSD 397

him- or herself of the trauma while at the site and then to notice everything
that has changed since the trauma. The first time the site visit is carried out,
the therapist is present and usually the parents are too.
8. Parent work. Parents of younger children are involved in treatment,
dependent on the clinical need. Older adolescents may come to treatment
without their parents. However, all parents are provided with psychoeduca-
tion and a description of the treatment. During therapy, the parents are fre-
quently invited to discuss their child’s progress, and parents can also request
sessions alone to alleviate their own stress related to their child’s trauma.

The treatment components are administered in a flexible and devel-

opmentally sensitive manner and do not follow a prescribed session-­ by-­
session approach but are administered throughout treatment as necessary
to address the model-­derived targets. (For further details, see Perrin et al.,
2017; Smith et al., 2010.)

Prolonged Exposure for Adolescents

Prolonged exposure for adolescents (PE-A) is an adaption of PE (see Riggs,
Tate, Chrestman, & Foa, Chapter 12, this volume). PE is based on the theory
that successful emotional processing of traumatic memories is the mecha-
nism of change and leads to a reduction in PTSD symptoms. Emotional
processing is primarily achieved through repeated imaginal exposure both
in the clinical office and between sessions. The adolescent adaptions specifi-
cally include increased family involvement in the treatment program by pro-
viding caregivers with psychoeducational information and tips to support
their children. There is additional focus on the social and developmental
considerations associated with adolescence. The model also has adjusted the
therapeutic exercises to be more developmentally congruent.
The treatment model is phase-based and consists of the following com-
ponents:

• Phase 1: Pretreatment preparation. A motivational interview is used to

enhance attendance and engagement if needed and address concrete
barriers to participation with case management.
• Phase 2: Psychoeducation and treatment preparation. Clients are provided
with information about trauma, trauma impact, and the therapeutic
rationale. Breathing retraining is introduced for coping with anxiety.
• Phase 3: Exposures. These modules are the majority of the treatment
focus (5–8 sessions). They include in vivo exposure to trauma remind-
ers, repeated imaginal exposure to the memory, and a worst moment’s
module. Imaginal exposure is tape-­recorded and youth are instructed
to listen to the tapes daily at home.
• Phase 4: Relapse prevention. In this phase the focus is on generalizing
the skills learned and preventing relapse.
398 Treatments for Children and Adolescents

Two studies with adolescents who have experienced single-­event trau-

mas have shown PE-A to be more effective in reducing posttraumatic stress
than time-­limited dynamic therapy (mostly related to motor-­vehicle acci-
dents; Gilboa-­Schechtman et al., 2010) and supportive counseling (related
to rape; Foa et al., 2013).

EMDR Therapy
EMDR therapy is an eight-phase approach that has some similar components
to CBT-T treatments but is unique in including rapid eye movement as an
important aspect of the intervention. During processing, the child is asked
to concentrate on the worst moment of the memory along with the concomi-
tant negative belief and physical sensation, while visually following the thera-
pist’s moving fingers. This is repeated with different aspects of the memory
until the child reports no further distress. Moving their eyes rapidly while
focusing on the traumatic memory may be difficult for younger children,
so tactile stimulation such as hand-­tapping or drumming is recommended.
The first two phases of EMDR therapy consist of assessing the child’s trauma
history, understanding the current trauma symptoms, and helping the child
cope. For example, relaxation exercises include visualizing a “safe place”
or other positive affect-­generating image. Assessment includes visualizing
aspects of the trauma, identifying negative body sensations and negative
thoughts associated with the traumatic event, and identifying a desired posi-
tive thought. Processing addresses all these elements related to the trauma
and current triggers. The treatment ends with addressing coping needs for
the future. Developmental modifications are recommended for young chil-
dren, such as the use of pictures and involving caregivers in treatment.
EMDR therapy is based on the adaptive information processing (AIP)
model, which posits that memories of disturbing events may be physiologi-
cally stored in unprocessed form, leading to problems in day-to-day function-
ing. Information-­processing systems facilitate the interpretation of current
experiences by linking them with previously established memory networks
of similar events. When confronted with a disturbing life experience, the
processing system does not always function optimally. The result is a failure
to process the event and it becomes “frozen in time,” incorporating the nega-
tive affects, sensations, and beliefs experienced at the time of the event. The
underlying basis for this dysfunction may be a failure of episodic memory
to be integrated into the semantic memory system so that inadequately pro-
cessed events are easily activated by both internal and external stimuli. In
contrast to behavioral models, the AIP model does not view negative self-­
characterizations as causes of emotional dysfunction but rather as symp-
toms. In contrast to CBT where therapeutic change occurs via behavioral,
narrative, and cognitive tasks, with EMDR therapy, change is conceptualized
as a consequence of memory processing through the internal associations
that are elicited during sets of bilateral stimulation (eye movements, taps,
Treatment of PTSD and Complex PTSD 399

or tones). For a more detailed description, see the work of Shapiro and col-
leagues (Shapiro, Russell, Lee, & Schubert, Chapter 14, this volume; Shap-
iro, Wesselmann, & Mevissen, 2017).
Although there has been more research conducted on the effectiveness
of EMDR therapy for adults (see Lee & Cuijpers, 2013, for an overview)
than for children and adolescents, evidence now exists that EMDR therapy
is also effective for youth (Rodenburg, Benjamin, de Roos, Meijer, & Stams,
2009). One study compared EMDR therapy and cognitive-­behavioral writ-
ing therapy (CBWT) for youth seeking treatment tied to a single trauma. At
posttreatment, 92.5% of those receiving EMDR therapy and 90.2% of those
receiving CBWT no longer met the diagnostic criteria for PTSD, and all
gains were maintained at follow-­up (de Roos et al., 2017). In one study, 48
Dutch children who had experienced single- or multiple-­event traumas were
randomized to receive eight sessions of TF-CBT or EMDR therapy. Both
treatments were equally effective in reducing posttraumatic stress symp-
toms. On comorbid problems, parents of children in the TF-CBT condition
reported more positive treatment effects than parents of children in the
EMDR therapy condition, possibly due to the inclusion of parents in TF-CBT
(Diehle, Opmeer, Boer, Mannarino, & Lindauer, 2015).

Recommended Treatments in School

and Group Settings

Applications of CBT-based trauma-­focused treatment elements for schools

and school-­like group settings (summer camps, after-­school programs) have
been under development for the past few decades. Socioeconomically disad-
vantaged children have the greatest difficulty accessing mental health services
(U.S. Public Health Service, 2000), and traumatized individuals are also less
likely to seek health services than their nontraumatized counterparts (Guter-
man, Hahm, & Cameron, 2002). Thus, the most vulnerable youth are those
least likely to ever receive traditional clinic-­based mental health care. An
example from trauma-­focused treatment comes from a study conducted fol-
lowing a disaster (Jaycox et al., 2010). Children were randomized to receive the
school-­based group intervention (CBITS) or TF-CBT delivered at a commu-
nity clinic. All children benefited from the interventions. However, far more
children accessed the school-­based treatment than the clinic-­based treatment
despite extensive efforts to support TF-CBT participation during the study.
Schools can serve an important role in addressing unmet mental health needs
following trauma, especially when the trade-off might be no treatment.
The school-/group-based interventions tend to take two forms: (1) inter-
ventions designed for “at-risk” students or (2) school-­based treatment for
children with trauma-­related symptoms (traumatic stress).
Most school programs developed to date are intended for at-risk stu-
dents and include a screening or identification process to determine which
400 Treatments for Children and Adolescents

students might benefit from the intervention. School intervention programs

for traumatic stress (including PTSD and related symptoms) are trauma-­
focused, developmentally oriented, and incorporate the core components
common to many trauma-­focused interventions as described earlier. More-
over, they are designed to fit into the school culture and meet logistical
constraints. To date, there have been few rigorous evaluations of such pro-
grams. Of over 30 programs reviewed, only five have evidence of impact
from randomized or quasi-­experimental controlled trials. Five programs
have been developed specifically for use in schools and focus on a broad
array of traumas:

1. The Cognitive-­Behavioral Intervention for Trauma in Schools (CBITS;

Jaycox et al., 2010; Kataoka et al., 2003; Stein et al., 2003) was evaluated first
in a quasi-­experimental study with students who were recent immigrants to
Los Angeles (Kataoka et al., 2003) and then in a randomized trial (Stein et
al., 2003). Results demonstrated a significant decrease in PTSD and depres-
sive symptoms in the group of students who received CBITS as compared to
those on a waiting list, as well as improved grades among those who received
CBITS earlier in the year compared to those who received it later in the
year (Kataoka et al., 2011). A field trial in New Orleans following Hurri-
cane Katrina showed comparable results in terms of reductions in PTSD and
depression scores among those randomized to CBITS as well as those who
received trauma-­focused CBT (Jaycox et al., 2010). The addition of a family
component showed that parent functioning can be improved alongside child
improvements (Santiago, Lennon, Fuller, Brewer, & Kataoka, 2014).
2. An adaptation of CBITS for younger elementary students (grades
K–5) called Bounce Back has demonstrated improved child outcomes (in
terms of PTSD and anxiety symptoms) in an RCT as compared to a wait-list
group (Langley, Gonzalez, Sugar, Solis, & Jaycox, 2015).
3. An adaptation of CBITS for delivery by nonclinical school personnel
called Support for Students Exposed to Trauma has demonstrated improved
outcomes (reductions in PTSD symptoms and depression), but no changes
in parent- or teacher-­reported behavior problems, in one randomized pilot
study (Jaycox et al., 2009).
4. Trauma-­Focused Coping in Schools (previously known as Multimodality
Trauma Treatment) was evaluated with a staggered start date control design
and showed decreases in PTSD, depressive, and anxiety symptoms among 14
treated students (March, Amaya-­Jackson, Murray, & Schulte, 1998). These
effects were replicated in subsequent studies (Amaya-­Jackson et al., 2003).
5. The UCLA Trauma and Grief Component Therapy for Adolescents Pro-
gram showed reductions in PTSD and grief symptoms and improvements in
GPA among 26 participants in an open trial, but did not exhibit changes in
depressive symptoms (Layne, Pynoos, & Cardenas, 2001; Saltzman, Pynoos,
Treatment of PTSD and Complex PTSD 401

Layne, Steinberg, & Aisenberg, 2001). A brief version of the program dem-
onstrated reductions in PTSD symptoms in two field trials following an
earthquake in Armenia (Goenjian, Karayan, & Pynoos, 1997; Goenjian et
al., 2005). In addition, the program was implemented in postwar Bosnia
(Layne, Pynoos, & Saltzman, 2001), showing greater reductions in PTSD,
depression, and maladaptive grief within the full program as compared to
an active comparison condition, with both groups improving significantly
(Layne et al., 2008). All five draw on evidence-­based practices for trauma,
largely cognitive-­behavioral techniques, and all have empirical support for
the reduction of trauma-­related symptoms.

There also have been some notable international efforts of school-­based

interventions in regions affected by disaster or ongoing terrorist threat.
These are typically CBT-based trauma treatments containing the common
CBT elements. An eight-­session program for grades 2–6 called Overshad-
owing the Threat of Terrorism (OTT) has been used and evaluated in Israel
(Berger, Pat-­Horenczyk, & Gelkopf, 2007), showing reduced PTSD, somatic,
and anxiety symptoms 2 months after the intervention among children who
took part. A related program, more curricular in nature, is Enhancing Resil-
ience among Students Experiencing Stress (ERASE-S), designed to mitigate the
effects of ongoing terrorism. ERASE-S uses teachers to deliver the material
and has demonstrated improved outcomes in terms of PTSD and anxiety, as
well as reduced stereotypes and discriminatory behaviors (Berger, Gelkopf,
& Heineberg, 2012; Berger, Gelkopf, Heineberg, & Zimbardo, 2016; Gelkopf
& Berger, 2009). Another study of children exposed to continuing violence
in Palestine examined teaching recovery techniques and found a positive
impact on PTSD symptoms (Barron, Abdallah, & Smith, 2013).
On the other hand, some studies have not shown positive effects on
posttraumatic stress symptoms but have other positive outcomes. A cluster-­
randomized school study of intervention for war-­exposed migrants in Aus-
tralia did not show improvement in PTSD symptoms, but on depressive
symptoms (Ooi et al., 2016), and several studies of war-­exposed children
show mixed or null findings on PTSD symptoms (Tol et al., 2008, 2014).
In addition to interventions developed specifically for use in schools,
it is also possible to bring clinical services onto school campuses or into
school-­like settings, and to adapt them somewhat to fit the institution’s con-
text and culture. Implementing these types of interventions comes with its
challenges, including more intensive training and supervision for clinicians,
fitting the sessions into the school day, and handling logistical issues such
as space and privacy. Despite these challenges, such interventions can be
good options for students with demonstrated clinical needs. Interventions
currently and commonly implemented in schools and school-­like settings
include an adaptation of a TF-CBT (Cohen et al., 2004) described earlier.
Another example of efforts to bring clinical treatments into schools or
other nonclinic settings is Community Outreach Program—­Esperanza (COPE;
402 Treatments for Children and Adolescents

de Arellano et al., 2005), which integrates the core components of a TF-

CBT package with enhanced support for parents, active outreach and case
management for children ages 4–18. Life Skills, Life Stories (Cloitre, Koenen,
Cohen, & Han, 2002) is a clinical program for women that was adapted for
female high school students with a history of sexual victimization and child
abuse. A version for adolescents, called STAIR-A, was tested within schools
in a quasi-­experimental study and found to reduce depressive symptoms and
improve some aspects of functioning (Gudiño, Leonard, & Cloitre, 2016).
In juvenile justice settings and schools, Trauma Adaptive Recovery Group
Education and Therapy for Adolescents (TARGET-­A; Ford, Mahoney, & Russo,
2001) focuses on body self-­regulation, memory, interpersonal problem solv-
ing, and stress management for youths ages 10–18 affected by physical or
sexual abuse, domestic or community violence, or traumatic loss.
Finally, there is work adapting interventions for residential treatment
settings and schools. For instance, Structured Psychotherapy for Adolescents
Responding to Chronic Stress (SPARCS; DeRosa & Pelcovitz, 2009) for teens
exposed to chronic interpersonal traumas combines CBT and dialectical
behavior therapy approaches (including mindfulness) to improve coping,
affect regulation, relationships, and functioning in the present.

Complex PTSD

During the last two decades, there have been a number of attempts to define
a broader category of trauma-­related psychopathological sequelae, most of
them referring to adults. Of the few definitions attempted for children and
adolescents, some focused on specific traumatic events, for example, recur-
ring sexual child abuse, and others comprised a broader range of symptoms
beyond specific PTSD symptoms. Developmental trauma disorder was pro-
posed for inclusion in DSM-5, but it was finally not included on the basis of
insufficient empirical support (Schmid, Petermann, & Fegert, 2013). ICD-11
includes a new category of complex PTSD, which is meant to be applicable
to children and adolescents as well. Beyond the three unique PTSD symp-
tom clusters (reexperiencing, avoidance, startle/hypervigilance), at least
one symptom is needed to be present in each of the three CPTSD-­specific
symptom clusters referred to as disturbances in self-­organization: affect dys-
regulation, negative self-­concept, and interpersonal problems (World Health
Organization, 2018). Yet, given the developmental considerations discussed
previously, some of the described symptoms are not to be regarded as psycho-
pathological at a certain age. For example, temper tantrums (dysregulation)
may be considered normal or pathological depending on the child’s age. As
we do not have strictly defined diagnostic boundaries (e.g., exactly when
temper tantrums become psychopathological), some of the CPTSD criteria
will remain difficult to disentangle from the developmental stage. Further-
more, the symptoms contained in the disturbances of self-­organization are
Treatment of PTSD and Complex PTSD 403

not necessarily specific to trauma impact but may be better and more parsi-
moniously explained by other disorders or comorbidities, or be premorbid
risk factors for more severe and pervasive trauma impact (see ISTSS, 2018).
At present, there are neither specific instruments available for assess-
ing CPTSD, nor do we have treatment studies for children and adolescents
based on the respective diagnostic criteria. Thus, currently most research
focuses on post hoc analyses.
Publications concerning diagnosing CPTSD use items extracted from a
number of instruments, interviews, and self-­report measures, and are there-
fore best regarded as approximations. First results support the notion that
PTSD and CPTSD can be differentiated, based on data from an RCT com-
paring TF-CBT with a wait-list control (Goldbeck et al., 2016) in children
and adolescents with PTSD associated with mixed traumatic events. Latent
class analysis resulted in two distinct classes, PTSD and CPTSD (Sachser,
Keller, & Goldbeck, 2017). Considering the small data pool and that the
measures were not specifically adapted to cover CPTSD, these are promising
first results that CPTSD may be a relevant diagnostic category.
Yet, the final and more important test of this construct is whether we
need specific interventions for CPTSD as compared to PTSD in children and
adolescents. As young people with CPTSD were included in treatment studies
on pediatric PTSD, secondary analysis should reveal if there is a differential
outcome. Sachser and colleagues (2017) did not find a differential treatment
response in the above-­mentioned trial by Goldbeck and colleagues (2016).
Overall, participants benefited from TF-CBT, with participants with CPTSD
beginning and finishing treatment with a higher symptom load. This would
be consistent with other childhood disorders where children with more
severe clinical presentations tend to benefit by the standard evidence-­based
treatments but have higher symptoms at the end of treatment trials. From a
clinician’s view, the question arises whether CPTSD patients need a higher
treatment dose or a different treatment model.
Treatment models applying a phase-based approach that begins with
emotion regulation skills and then is followed by the trauma-­focused CBT
have thus far mostly been tested in adults. They assume that fostering emo-
tion regulation techniques before starting a trauma-­focused intervention is
beneficial in the treatment of CPTSD. Yet, many phase-based interventions
were developed before the CPTSD definition became available (for instance,
TF-CBT) and therefore targeted other definitions of complex trauma-­related
disorders. One of these phase-based interventions is Skills Training in Affect
and Interpersonal Regulation (STAIR; Cloitre, Cohen, & Koenen, 2006),
which was developed for adults with PTSD related to sexual abuse in child-
hood. STAIR was then adapted to adolescents (STAIR narrative therapy for
adolescents [SNT-A]). SNT-A is a cognitive-­behavioral intervention begin-
ning with a skills training module (about 8–12 sessions), followed by four
to eight sessions of a narrative therapy module (Gudiño, Leonard, Stiles,
Havens, & Cloitre, 2017). Although some studies support STAIR, there is
404 Treatments for Children and Adolescents

ongoing discussion on how to appraise these findings (De Jongh et al., 2016).
Concerning the adaptation of STAIR to adolescents, only two studies have
been published to date (Gudiño et al., 2014, 2016), one of them with a con-
trolled design, where no significant improvement in PTSD symptoms was
found (Guidiño et al., 2016).
Another stepped treatment approach is a developmentally adapted ver-
sion of cognitive processing therapy (CPT), where CPT was not only adapted
to the respective age group but preceded by a commitment phase to enhance
treatment motivation and therapeutic alliance and by an emotion regula-
tion training phase. The approach was tested in an uncontrolled pilot study
(Matulis, Resick, Rosner, & Steil, 2014), showing large effect sizes, and in an
RCT (Rosner et al., 2019). In the RCT, young people with PTSD related to
sexual and/or physical abuse were compared with a usual care condition.
The developmentally adapted CPT was highly effective in reducing posttrau-
matic symptom severity as well as comorbid symptoms compared to usual
care. An analysis of treatment course revealed that changes in posttraumatic
symptom severity occurred during the core CPT phase. Further studies are
needed to clarify whether such preceding modules (e.g., emotion regulation
or skills training) are necessary before starting trauma-­focused interven-
tions in young patients with CPTSD.
Summarizing the currently available empirical literature, no recom-
mendation concerning the treatment of CPTSD can be given at the moment,
other than that the first-line interventions for PTSD described in this chap-
ter may be helpful.

Pharmacological Interventions for PTSD

The list of recommendations for pharmacological interventions in children

and adolescents can be seen in Table 21.2. Several neurotransmitter systems
are implicated in the development and maintenance of pediatric PTSD, and

TABLE 21.2. Recommendation for Psychopharmacological Treatment

Prevention/early intervention
Insufficient Evidence to Recommend—There is insufficient evidence to
recommend propranolol, within the first 3 months of a traumatic event,
as an early pharmacological intervention to prevent clinically relevant
posttraumatic stress symptoms in children and adolescents.

Treatment
Insufficient Evidence to Recommend—There is insufficient evidence to
recommend sertraline for the treatment of children and adolescents
with clinically relevant posttraumatic stress symptoms.
Treatment of PTSD and Complex PTSD 405

pharmacological treatment for pediatric PTSD is widespread. However,

there have been only a few RCTs examining the efficacy of pharmacological
agents to treat pediatric PTSD, and to date none of these has documented
the efficacy of medication for this population. Due to developmental dif-
ferences, adult pharmacological studies cannot be extrapolated to children
and adolescents. In PTSD, this has been shown with the SSRI antidepressant
sertraline that, although efficacious for adult PTSD, was not superior to
placebo in improving PTSD in children and adolescents in a multisite RCT
(Robb, Cueva, Sporn, Yang, & Vanderburg, 2010). This finding was rein-
forced in a small RCT that examined TF-CBT + sertraline versus TF-CBT
+ placebo, which did not find significant differences between conditions
in improving PTSD (Cohen, Mannarino, Perel, & Staron, 2007). Two addi-
tional RCTs in youth evaluated the beta-­adrenergic blocking agent propran-
olol versus placebo and determined no significant differences (Nugent et
al., 2010; Sharp, Thomas, Rosenberg, Rosenberg, & Meyer, 2010), although
the former study found a significant interaction between gender and treat-
ment group among medication-­adherent youth, with males responding bet-
ter to propranolol treatment. Another study similarly found no differences
between the NMDA partial agonist d -cycloserine + CBT versus placebo +
CBT (Scheeringa & Weems, 2014), although there was a trend toward the
active medication group speeding recovery during the exposure sessions.
More studies with larger pediatric samples are needed to clarify what medi-
cations may be helpful for which subsamples of youth with PTSD. At the
current time, evidence-­based trauma-­focused psychotherapy is the first line
of treatment for pediatric PTSD. Psychopharmacology should only be used
to treat co-­occurring conditions with evidence-­based pharmacological treat-
ments, or to target specific symptoms that are carefully and systematically
tracked.

Future Developments

In summary, the ISTSS Posttraumatic Stress Disorder Prevention and Treatment

Guidelines’ scientific review of treatments of PTSD and clinically significant
posttraumatic stress in children strongly recommend different models of
CBT with a trauma focus and EMDR therapy. This means we can confidently
recommend these treatments to children and families with an expectation
of good results.
It seems likely that other versions of trauma-­focused treatments that
may not have quite the same level of empirical support but contain some or
all of the common elements as the recommended CBT interventions could
be potentially beneficial when the strongly recommended approaches are
not available. The main differences among the recommended treatments
are (1) the relative emphasis on exposure and cognitive processing and
how they are implemented, (2) the timing and amount of focus on teaching
406 Treatments for Children and Adolescents

coping skills of various kinds, (3) the degree to which (if at all) parents are
included in treatment. Due to the similarities in outcomes across CBT mod-
els, it is unlikely that research resources will be allocated for large head-to-
head comparisons of different models, although more head-to-head studies
of trauma-­focused CBT models and EMDR therapy may be warranted.
School and group interventions do not reach the same level of effect
sizes as treatments delivered individually. They may, however, be beneficial
in situations where many are affected or where services are limited. CBT for
parents alone does not have a Strong recommendation, and studies show that
improving parent stress does not improve child posttrauma symptoms (Holt,
Jensen, & Wentzel-­Larsen, 2014).
We need to know more about the relative importance, temporal order-
ing, and dosage of the different components for the different presentations
of children affected by trauma. Some children will not need the full course
of the recommended treatments, so stepped care may be the better option,
and current studies are examining stepped-­care models of TF-CBT to evalu-
ate “who needs what” components (Salloum et al., 2016). Gender effects
and the sequencing of interventions targeting comorbid syndromes such
as substance abuse or prolonged grief need to be examined, too. We also
need to better understand what the mechanisms of change may be in dif-
ferent interventions. Dismantling studies and therapy process analysis could
help us understand what components are necessary and help target inter-
ventions for the individual child and family. In the future, it is possible that
such efforts will enable clinicians to optimally tailor treatment to best fit
the needs of individual traumatized children and families. Some children
do not benefit sufficiently from the standard recommended approaches. It
will be especially important to confirm if CPTSD exists as a separate clinical
phenomenon versus representing a more severe version of PTSD, if entirely
new treatments or treatment components are needed, or if increasing the
dosage of certain components or extending standard treatments will be
effective. And finally, we need more studies on the implementation of inter-
ventions. Having several effective treatments is not helpful if they cannot be
delivered in real-world settings.

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PA R T VI

APPLICATION, IMPLEMENTATION,
AND FUTURE DIRECTIONS
C H A P TE R 2 2

Treatment Considerations
for PTSD Comorbidities
Neil P. Roberts, Sudie E. Back, Kim T. Mueser,
and Laura K. Murray

C omorbidity is the norm for posttraumatic stress disorder (PTSD). It is

estimated that, in the general population, over 80% of individuals with
PTSD will experience at least one additional lifetime mental health disorder,
and around 50% will experience three or more comorbidities (Kessler, Son-
nega, Bromet, Hughes, & Nelson, 1995). Among clinical populations, the
rates of comorbidity can exceed 90% (Brown, Campbell, Lehman, Grisham,
& Mancil, 2001; Richardson et al., 2017).
Conceptual, clinical, and causal relationships between PTSD and other
conditions are complex and multifaceted (Lockwood & Forbes, 2014). A
range of factors have been implicated as conferring vulnerability or playing
a causal role in PTSD comorbidity, including gender, socioeconomic status,
genetics, childhood trauma, and certain personality traits (e.g., Lockwood
& Forbes, 2014; Müller et al., 2014). PTSD is often perceived as mediating
the relationship between trauma experience and the onset of a comorbidity
(van Minnen, Zoellner, Harned, & Mills, 2015), but evidence from a number
of studies suggests that the relationship between PTSD and other disorders
is often bidirectional and includes a range of shared common features and
underlying vulnerabilities (Lockwood & Forbes, 2014). Mental and physi-
cal health comorbidities have been shown to have a major impact on PTSD
symptom trajectories and are associated with poor health-­related quality of
life (Li, Zweig, Brackbill, Farfel, & Cone, 2018). Network approaches suggest
that there may be “many roads to comorbidity,” such that for a given person,
the causal chain of symptom interactions is likely to be highly individual-
ized and shaped by specific personal factors and events (Borsboom, Cramer,
Schmittmann, Epskamp, & Waldrop, 2011).

417
418 Application, Implementation, and Future Directions

There is increasingly robust evidence for a range of psychological and

pharmacological interventions for PTSD. These psychological treatments,
designed for one specific/primary disorder, PTSD, are often referred to
as “disorder-­specific treatments.” Historically, disorder-­specific treatments
have been evaluated in more tightly controlled efficacy trials and have sig-
nificantly advanced the field by generating a body of research leading to
the availability of evidence-­based treatments (EBTs). However, many trials
exclude individuals with more clinically challenging comorbidities, such as
substance use disorders, psychosis, personality disorders, persistent self-­
harming, and suicidality, because these individuals tend to have more severe
clinical profiles (Roberts, Roberts, Jones, & Bisson, 2015; van Minnen et al.,
2015). Individuals with multiple comorbidities tend to have poorer function-
ing and well-being, and inferior treatment outcomes (Müller et al., 2014;
Roberts et al., 2015; Schäfer & Najavits, 2007). Clinicians are often reluctant
to use some EBTs because they fear that PTSD or comorbid symptoms will
become exacerbated (van Minnen, Harned, Zoellner, & Mills, 2012; van Min-
nen et al., 2015). Comorbidity therefore can provide a particular challenge
for clinicians in terms of prioritizing treatment goals, how to manage risk,
and how to deliver an optimal intervention.
There has been growing research on a single comorbid condition with
PTSD, or PTSD plus one other disorder (recognizing that individuals with
the comorbidity for inclusion may have other comorbidities as well). Some
emerging options for treatment of PTSD plus comorbid conditions include
(1) utilizing a PTSD-­focused EBT and examining the effects of the comor-
bid conditions (e.g., how much a PTSD treatment affects depression), (2)
using EBTs for the two conditions sequentially, (3) integration of two EBTs
to address both conditions simultaneously (e.g., PTSD and panic), and (4)
transdiagnostic models that address multiple problem areas (e.g., Mansell,
Harvey, Watkins, & Shafran, 2009; Marchette & Weisz, 2017).
Specific scoping questions related to comorbidity issues were not
included in the current revised Posttraumatic Stress Disorder Prevention and
Treatment Guidelines released by the International Society for Traumatic
Stress Studies (ISTSS) (see Bisson, Lewis, & Roberts, Chapter 6 and Bisson
et al., Chapter 7, this volume), so the guidelines may have limitations when it
comes to generalizing recommendations for some comorbid disorders (Lug-
tenberg, Burgers, Clancy, Westert, & Schneider, 2011). In this chapter, we
consider some of the challenges and debates related to PTSD comorbidities,
the relationship between PTSD and other disorders, comorbid treatment
approaches and their evidence, and recommendations for future research.
We focus on six types of PTSD and a comorbidity among adult populations:
depression, panic, substance use disorders, psychosis, borderline personality
disorder, and chronic pain, as these are among the most common and chal-
lenging comorbidities faced by clinicians treating individuals with PTSD.
We briefly review child comorbidity, focusing on internalizing and external-
izing symptoms overlapping with PTSD, rather than paired comorbidities.
Treatment Considerations for PTSD Comorbidities 419

For each comorbidity, we review EBTs that are commonly used, which have
historically been disorder-­specific treatments, and, where available, review
the use of sequential or integrated approaches. Finally, we briefly review
emerging research on transdiagnostic interventions for PTSD and its comor-
bidities.

Adult Comorbidity
Depression
Depression is the most common PTSD comorbidity, with around 50% of
PTSD sufferers meeting the diagnosis for major depressive disorder (MDD;
Rytwinski, Scur, Feeny, & Youngstrom, 2013). PTSD sufferers also demon-
strate elevated suicide risk (e.g., Panagioti, Gooding, & Tarrier, 2012). Indi-
viduals with depression are not usually excluded from PTSD trials, except
when there is a significant suicide risk, but the comorbidity is associated
with increased symptom severity and poorer functioning as compared to
either disorder alone (van Minnen et al., 2012). Clinicians are sometimes
concerned that it will be more difficult to engage patients with co-­occurring
depression in trauma processing work and to address rigid negative beliefs
reflecting feelings of hopelessness and guilt (van Minnen et al., 2012).
A range of explanations has been proposed to explain the association
between PTSD and depression. Prominent among these is that the rela-
tionship is a result of symptom overlap, particularly through symptoms of
dysphoria (e.g., poor sleep, concentration difficulties, anger, loss of inter-
est, negative appraisals about the self and world; see Flory & Yehuda, 2015;
Lockwood & Forbes, 2014). PTSD and depression also share common com-
ponents, such as negative cognitions, negative affect, restricted affect, and
avoidant behaviors (Horesh et al., 2017). Other explanations include PTSD
as the antecedent disorder (e.g., Ginzburg, Ein-Dor, & Solomon, 2010); a
depressogenic model, where depression leads to subsequent PTSD (e.g.,
King, King, McArdle, Shalev, & Doron-­LaMarca, 2009); and the argument
that each disorder is an independent consequence of trauma (Horesh et al.,
2017; Lockwood & Forbes, 2014). It has also been proposed that PTSD and
depression may be subclusters of a larger syndrome (Flory & Yehuda, 2015).
Evidence from prospective studies suggests that there is a complex temporal
relationship between the two disorders involving bidirectional causality and
a range of common risk factors (e.g., Ginzburg et al., 2010; Horesh et al.,
2017; Stander, Thomsen, & Highfill-­McRoy, 2014).
There is little literature on specific models of treatment for this comor-
bidity (Stander et al., 2014). Antidepressants can play a role in improving
symptoms of PTSD alongside depression, but their effects tend to be small
(see Bisson, Hoskins, & Stein, Chapter 16, this volume). The available evi-
dence also suggests that individuals with PTSD make only limited gains
from psychological interventions primarily aimed at treating depression (see
420 Application, Implementation, and Future Directions

Bisson et al., Chapter 7, this volume). However, depressive symptoms typi-

cally show medium to large pre- to posttreatment effect size improvements
alongside symptoms of PTSD with evidence-­based PTSD interventions, such
as prolonged exposure (PE; see Riggs, Tate, Chrestman, & Foa, Chapter
12, this volume), cognitive processing therapy (CPT; see Chard, Kaysen,
Galovski, Nixon, & Monson, Chapter 13, this volume), and eye movement
desensitization and reprocessing (EMDR) therapy (see Shapiro, Russell, Lee,
& Schubert, Chapter 14, this volume), in comparison to control conditions
(Bisson, Roberts, Andrew, Cooper, & Lewis, 2013; van Minnen et al., 2015).
There is some indication that improvement in depressive symptoms tends
to follow PTSD symptom improvement (van Minnen et al., 2015). However,
there is also some evidence from two studies in veteran populations inves-
tigating heterogeneity of treatment responses through latent class analysis
showing that higher depression scores predict poorer treatment outcomes
(Murphy & Smith, 2018; Phelps et al., 2018). This work points to the impor-
tance of careful assessment of depressive symptoms and of the development
of individualized treatment planning, which may sometimes indicate the
need for treatment of more severe depressive symptoms with medication or
an EBT for depression prior to engagement in EBT for PTSD when depres-
sive symptoms are severe and likely to inhibit engagement in PTSD treat-
ment. At such times, clinicians may want to give particular consideration
to treatment approaches that target both PTSD and depression symptoms,
such as CPT and cognitive therapy, particularly when problems like chronic
guilt are indicated (Phelps et al., 2018).

Panic Disorder
Data from the National Comorbidity Survey (Kessler et al., 1995) estimate a
lifetime prevalence of comorbid panic disorder and PTSD of around 11%,
with a higher prevalence for women than men. Other studies have found
far higher rates of panic symptoms in PTSD and traumatized populations,
with rates as high as 35% (e.g., Cougle, Feldner, Keough, Hawkins, & Fitch,
2010; Hinton, Pollack, Pich, Fama, & Barlow, 2005). Rates of comorbid
PTSD of around 30% have also been reported in panic disorder–­diagnosed
populations (e.g., Craske et al., 2006). Individuals with PTSD–panic disor-
der comorbidity have been shown to be increasingly vulnerable to other
comorbidities, such as substance abuse, suicidal behavior, chronic pain, and
medically unexplained symptoms, as well as interpersonal and occupational
impairments (see Cougle et al., 2010; Teng et al., 2013). The comorbidity is
also a unique predictor of more severe psychiatric disability compared to
those without panic attacks (Cougle et al., 2010).
PTSD and panic disorder share several overlapping features in hyper-
vigilance, autonomic reactivity, heightened perception of danger, and avoid-
ance of internal and external reminders (Teng et al., 2013). Panic attacks
in PTSD sufferers are often triggered by trauma-­related reminders (Teng
Treatment Considerations for PTSD Comorbidities 421

et al., 2013), and there is some indication that panic and agoraphobia tend
to develop following the onset of PTSD, rather than vice versa (Brown et
al., 2001). Surprisingly, there is a paucity of research aimed at understand-
ing the relationship between PTSD and panic disrder (Cougle et al., 2010;
Liness, 2009; Teng et al., 2013). One explanation for this relationship that
has some empirical support is “anxiety sensitivity” (Vujanovic, Zvolensky,
& Bernstein, 2008). Anxiety sensitivity is conceptualized as a fear of anxi-
ety and anxiety-­related physiological arousal, alongside fearful cognitions
related to somatic, psychological, and social concerns (Vujanovic et al.,
2008). It is argued that individuals who are prone to anxiety sensitivity have
a predisposition to become “emotionally alarmed” when they experience
anxiety, leading to an escalation in their symptoms (Vujanovic et al., 2008).
Anxiety sensitivity is therefore thought to be a contributory factor in the
development and maintenance of both disorders (Teng et al., 2013). From
a classical conditioning perspective, it has been argued that, in addition to
external cues, internal cues such as thoughts, feelings, and physiological
responses experienced at the time of a trauma may trigger activation of
the trauma memory network, resulting in panic responses (Falsetti, Resnick,
Dansky, Lydiard, & Kilpatrick, 1995; Hinton, Hofmann, Pitman, Pollock, &
Barlow, 2008). When an individual is unable to attribute a panic attack to
a triggering event, he or she may therefore believe that it has “come out of
the blue.” As a result of chronic hyperarousal from PTSD, small increases in
arousal may be sufficient to trigger a panic response (Falsetti et al., 1995).
The association between conditioned cues and responses is thought to be
further reinforced by avoidance behaviors that inhibit the opportunity for
new learning.
Individuals with PTSD–panic disorder are sometimes reluctant to
engage in trauma processing because of fears that their panic will escalate
and become uncontrollable (Liness, 2009). These fears can result in avoid-
ance of treatment sessions and dropout. Empirical evidence about the poten-
tial benefits of adapting existing PTSD therapies or developing alternative
treatment models remains limited (Teng et al., 2013). Anxiety symptoms
tend to improve in line with other symptoms in most clinical trials of psy-
chological interventions for PTSD (see Bisson et al., 2013; van Minnen et al.,
2015). However, few trials have reported on panic disorder as a diagnostic
outcome (Teng et al., 2013). In the small number of trials where panic dis-
order diagnostic status has been examined, a significant minority of par-
ticipants did not experience improvement in panic symptoms (Teng et al.,
2013). Treatments for the two disorders share some common features (e.g.,
psychoeducation, cognitive restructuring, exposure to feared situations;
Teng et al., 2013), and in some models, such as cognitive therapy, it may
be possible to incorporate intervention for panic into a PTSD-­related treat-
ment formulation (Liness, 2009). Drawing on common treatment processes,
Falsetti and colleagues (e.g., Falsetti, Resnick, & Davis, 2008) developed mul-
tiple channel exposure therapy (M-CET) to specifically treat PTSD–panic
422 Application, Implementation, and Future Directions

disorder. M-CET is a combined treatment, adapted from CPT and CBT for
panic, that addresses both disorders concurrently over 12 sessions (Falsetti
et al., 2008). Early sessions help patients reduce their fear of the physical
features of panic through interoceptive exposure to physiological reactions
to panic symptoms (i.e., inducing panic symptoms to facilitate habituation
to feared internal physical symptoms), which, it is argued, leads to a subse-
quent decrease in physiological arousal associated with these symptoms as
well as trauma-­related fear. This then allows therapy to address distorted
PTSD- and panic-­related appraisals simultaneously in subsequent sessions
(Falsetti et al., 2008). A culturally adapted version of M-CET has also been
developed for use with Southeast Asian refugees (Hinton, Pollack, et al.,
2005). Preliminary findings from several small randomized controlled trials
(RCTs; e.g., Falsetti et al., 2008; Hinton, Chhean, et al., 2005) are encourag-
ing, although it is not clear if this combined treatment improves panic and
PTSD outcomes beyond those of established PTSD therapies.

Substance Use Disorders

One of the most common co-­occurring mental health disorders among indi-
viduals with PTSD is substance use disorders (SUDs). A strong association
between PTSD and SUD is evidenced by data from large-scale epidemiologi-
cal studies as well as clinical studies on treatment-­seeking populations (e.g.,
Blanco et al., 2013; Gielen, Krumeich, Havermans, Smeets, & Jansen, 2014).
Data from the National Epidemiological Survey on Alcohol and Related
Conditions (N = 36,309) indicate that the lifetime prevalence of alcohol and
drug use disorders is 29% and 10%, respectively, in the United States (Grant
et al., 2016). Rates of SUD are significantly higher among individuals with
PTSD (Mills, Teesson, Ross, & Peters, 2006; Pietrzak, Goldstein, Southwick,
& Grant, 2012). In comparison to the general population, military veter-
ans are at increased risk for developing both PTSD and SUD (e.g., Petrakis,
Rosenheck, & Desai, 2011; Sabella, 2012). In a recent study of 26,754 newly
enlisted U.S. soldiers (N = 30,583), rates of PTSD were found to increase
in a dose-­response fashion as severity of substance use increased. Among
soldiers who binge-drink, rates of PTSD were approximately 15%, whereas
among soldiers with probable alcohol use disorder, rates of PTSD increased
to approximately 23% (Stein et al., 2017). Taken together, these data indicate
a high prevalence of co-­occurring PTSD and SUD across various popula-
tions.
Various hypotheses and theories have been proposed to help explain
the common co-­occurrence of PTSD and SUD. While no single theoreti-
cal model has received unequivocal empirical support, the self-­medication
hypothesis is among the most prominent. This hypothesis is that individuals
with PTSD use alcohol and drugs in an attempt to alleviate distressing PTSD
symptoms, such as trouble sleeping and intrusive memories (e.g., Back, 2010;
Back, Foa, et al., 2014; Khantzian, 1997). Support for the self-­medication
Treatment Considerations for PTSD Comorbidities 423

theory comes from daily diary studies that show individuals consume more
alcohol on days that they experience more PTSD symptoms (e.g., Dvorak,
Pearson, & Day, 2014; Kaysen, Stappenbeck, Rhew, & Simpson, 2014). In
addition, research on the temporal order of onset demonstrates that the
onset of PTSD typically precedes the development of SUD (e.g., Back, Jack-
son, Sonne, & Brady, 2005; Mills et al., 2006). On average, adults with PTSD-
SUD report exposure to their first traumatic event around age 8–10 (Mills et
al., 2012; Persson et al., 2017). Furthermore, compelling data in support of
the self-­medication hypothesis are provided by studies showing that improve-
ments in PTSD severity have a greater impact on improvements in SUD than
vice versa (Back, Brady, Sonne, & Verduin, 2006; Hien et al., 2010).
Several other theories have been put forward to help shed light on the
complex relationship between PTSD and SUD. One theory posits that indi-
viduals with SUD are at increased risk for experiencing potentially trau-
matic events, which may lead to PTSD, such as car accidents or sexual assault
(Schäfer & Najavits, 2007; Testa & Livingston, 2009). This increased risk
could be due to cognitive impairment as a result of chronic substance use
and factors associated with a high-risk lifestyle. In addition, a growing body
of literature identifies shared neurobiological factors associated with both
conditions (Brady & Sinha, 2005; Gilpin & Weiner, 2017). For example, both
PTSD and SUD are associated with dysregulation in corticolimbic struc-
tures, in particular, the amygdala (associated with emotional valance and
fear extinction) and the prefrontal cortex (associated with executive func-
tioning, decision making, and response inhibition). Dysregulation in these
areas may reduce the ability to use “top-down control” to regulate intrusive
memories, cravings, and thoughts about using substances. Alternations in
the hypothalamic–­pituitary–­adrenal (HPA) axis and noradrenergic systems
have also been identified as key components in the development and main-
tenance of PTSD and SUD (Brady & Sinha, 2005). While the contribution of
neurobiological and genetic factors to the etiology of PTSD-SUD is not com-
pletely understood, there is evidence of shared underlying processes that
may increase the risk of developing both conditions and serve as important
prevention and treatment targets.
PTSD-SUD presents numerous clinical challenges, even to the most
seasoned mental health professional. Patients with PTSD-SUD present
with a more severe clinical profile, including a greater number of mental
health comorbidities, more functional impairment (e.g., physical, cogni-
tive), increased violence, higher rates of homelessness, and poorer treat-
ment outcomes (Barrett, Teesson, & Mills, 2014; Blanco et al., 2013; Bowe &
Rosenheck, 2015; Mills et al., 2006; Norman, Haller, Hamblen, Southwick,
& Pietrzak, 2018; Roberts et al., 2015). In addition, patients with PTSD-SUD
have high rates of suicidal ideation and attempts (Back et al., 2019; Norman
et al., 2018; Mills et al., 2012). Given the severity of mental, physical, and
functional impairment that is often characteristic of patients with PTSD-
SUD, it is not surprising that clinicians perceive the dual diagnosis to be
424 Application, Implementation, and Future Directions

substantially more difficult to treat than either disorder alone (Back, Wal-
drop, & Brady, 2009; Gielen et al., 2014; Schäfer & Najavits, 2007). Com-
mon difficulties reported by clinicians in treating patients with PTSD-SUD
include self-­destructive behaviors and heavy case management needs (e.g.,
housing).
Clinicians also report the challenge of uncertainty regarding how to
implement treatment. Questions on whether to refer PTSD-SUD patients to
addiction treatment first and knowing when to initiate EBTs for PTSD are
common (Adams et al., 2016; Back et al., 2009). This relates to a larger debate
concerning which approaches, sequential or integrated focal treatments,
are optimal. Historically, patients with PTSD-SUD have been referred to
SUD-only treatment first and, following successful completion of SUD-only
treatment, are then referred for PTSD treatment (van Dam, Vedel, Ehring,
& Emmelkamp, 2012). Indeed, only a minority of treatment facilities have
been found to provide integrated PTSD and SUD care (Substance Abuse
and Mental Health Services Administration [SAMHSA], 2016). In a study
investigating the reasons why clinicians do not implement integrated treat-
ments, Gielen and colleagues (2014) found that many SUD clinicians under-
estimated the prevalence of comorbid PTSD-SUD, and expressed practical
barriers such as lack of time, limited facility funds, and lack of expertise. In
addition, clinicians expressed the belief that integrated treatment of PTSD
and SUD would “cause more misery,” increase craving, and impede addic-
tion treatment. However, the majority of patients with PTSD-SUD perceive
their symptoms to be related and prefer integrated treatment in which both
their PTSD and SUD are addressed concurrently (Back, Killeen, et al., 2014).
Importantly, empirical data from the past two decades support the safety
and efficacy of integrated treatments in significantly reducing PTSD, SUD
severity, and associated areas of impairment, such as depression (Back et al.,
2019; Norman et al., 2019; Roberts et al., 2015; Simpson, Lehavot, & Petra-
kis, 2017; van Dam et al., 2012).
Retention is another salient challenge in treating PTSD-SUD. In a
meta-­analysis of 42 studies examining treatments for PTSD, Imel, Laska,
Jakupcak, and Simpson (2013) found that the average dropout rate was 18%.
Dropout rates for PTSD treatment may be higher among military veterans
(Myers, Haller, Angkaw, Harik, & Norman, 2019). Data from the Substance
Abuse and Mental Health Services Administration indicate that, across vari-
ous types of addiction services (e.g., outpatient, residential, detoxification),
approximately 45–65% complete treatment (SAMHSA, 2015; Stahler, Men-
nis, & DuCette, 2016). And, in a recent review of PTSD-SUD patients receiv-
ing three types of treatments (exposure based, coping based, and addiction
focused), approximately 50% of patients overall completed treatment (Simp-
son et al., 2017). Interestingly, studies examining treatment dropout reveal
that a substantial proportion (36–68%) of patients who drop out before com-
pleting treatment evidence clinically significant improvement or meet good
end-state functioning with regard to PTSD and/or SUD symptoms prior to
Treatment Considerations for PTSD Comorbidities 425

dropping out (Szafranski et al., 2017, 2018), suggesting that dropout is not
always due to a worsening or lack of symptom improvement. Nonetheless,
attrition is a common problem in treating PTSD-SUD, and more effective
methods for retaining patients are needed.
To date, patients presenting with co-­occurring PTSD-SUD have often
received sequential treatment in which patients first complete SUD-only treat-
ment and are then referred to PTSD-only treatment, generally provided
by a different clinician. There is significant potential within the sequential
treatment model, however, for patients to “fall through the cracks” and not
complete either the SUD or PTSD treatment sequence. Proponents of the
integrated treatment model assert that PTSD symptoms may, at least in
part, contribute to alcohol and drug use problems, and that untreated PTSD
symptoms increase the risk of relapse. In so far as co-­occurring SUD rep-
resents a form of self-­medication of PTSD symptoms, addressing the PTSD
early in treatment may help optimize long-term outcomes (Hien et al., 2010;
McCauley, Killeen, Gros, Brady, & Back, 2012). Furthermore, as noted, a
substantial proportion of patients with PTSD and SUD prefer an integrated
treatment.
Integrated treatment efforts are often categorized into one of two
groups using various terminology: (1) exposure-­ based, trauma-­ focused,
or past-­focused treatments; and (2) coping-­based, non-­trauma-­focused, or
present-­focused treatments. Treatments from the first category incorporate
PE (Back, Foa, et al., 2014; Foa, Gillihan, & Bryant, 2013; Mills et al., 2012;
Norman et al., 2019; Persson et al., 2017; Ruglass et al., 2017) or compo-
nents of PE, such as imaginal, in vivo, or written exposure exercises (e.g., van
Dam, Ehring, Vedel, & Emmelkamp, 2013). Other integrated interventions
include psychoeducation and components of CPT to address both PTSD and
SUD (McGovern, Lambert-­Harris, Alterman, Xie, & Meier, 2011; Vujanovic,
Smith, Green, Lane, & Schmitz, 2018). In contrast, treatments from the sec-
ond category do not discuss or talk about the traumatic event, but rather
focus on present-­day coping skills, such as self-care, increasing compassion
and honesty, and detaching from emotional pain (e.g., Boden, Bonn-­Miller,
Kashdan, Alvarez, & Gross, 2012; Frisman, Ford, Hsiu-Ju, Mallon, & Chang,
2008; Hien et al., 2009; Myers, Browne, & Norman, 2015). The most com-
monly researched coping-­based treatment is Seeking Safety, a 25-session
manualized intervention (Najavits, 2002).
In the most recent and comprehensive review of psychological inter-
ventions for PTSD-SUD, Simpson and colleagues (2017) examined 24 ran-
domized clinical trials (N = 2,294). Among exposure-­based treatments, the
findings revealed significantly better PTSD outcomes with exposure-­based
treatment as compared to the control group in six out of seven studies. SUD
outcomes were comparable, though not significantly better, in most stud-
ies of exposure-­based integrated treatments. Among coping-­based studies,
no between-­g roup differences in PTSD outcomes between the coping-­based
treatment and the control condition were revealed. Similar findings were
426 Application, Implementation, and Future Directions

reported in an earlier review of 14 studies (N = 1,506 participants), which

found more favorable PTSD treatment outcomes and comparable SUD out-
comes for individual-­ based, trauma-­ focused interventions delivered con-
currently alongside a SUD intervention (Roberts et al., 2015). The findings
from these reviews and other investigations (Back et al., 2019; Norman et al.,
2019) provide evidence that exposure-­based integrated treatments are effec-
tive for PTSD-SUD, and that the addition of trauma-­focused interventions
does not increase substance use or risk for relapse. Hence, patients present-
ing with co-­occurring PTSD-SUD should be offered integrated treatment
or EBT for PTSD without waiting for abstinence. Of note, one study found
that only about half of PTSD-SUD patients endorse a goal of abstinence
(Lozano et al., 2015), and outcomes from the integrated studies mentioned
here indicate that, even for patients who do not achieve abstinence, a signifi-
cant reduction in PTSD symptoms can be attained.
Although important advances have been made in the development of
integrated treatments for comorbid PTSD-SUD, much work remains to opti-
mize interventions and to identify the underlying mechanisms of action.
Exploration of novel pharmacological interventions that may help further
reduce SUD symptomatology, such as cravings and substance use, would
be beneficial. More work on the shared neurobiology associated with PTSD
and SUD is needed to help elucidate the biological underpinnings of this
comorbidity and identify novel treatment targets. Finally, research on the
development of novel ways to enhance retention is needed for patients with
PTSD-SUD.

Severe Mental Illness

The term “psychotic disorders” is used most often to refer to schizophrenia-­
spectrum disorders (schizophrenia; schizoaffective disorder; schizophreni-
form disorder, hereafter referred to as schizophrenia) and other relatively
uncommon disorders such as brief psychotic disorder or psychotic disorder
not otherwise specified (American Psychiatric Association, 2013). However,
this term is somewhat of a misnomer because it implies that psychotic symp-
toms (e.g., hallucinations, delusions, bizarre behavior) are the most impor-
tant clinical feature distinguishing these disorders from others. In fact,
grandiosity is included as a criterion for the diagnosis of a manic episode
in bipolar disorder, and loss of insight is a common problem. Additionally,
other psychotic symptoms (e.g., hallucinations, delusions) are often present
during manic and depressive episodes of bipolar disorder or major depres-
sion, including depression with comorbid PTSD (Gottlieb, Mueser, Rosen-
berg, Xie, & Wolfe, 2011). Furthermore, episodes of depression or mania
can occur in schizophrenia. What distinguishes the two groups of disorders
is that there must be some evidence for the presence of psychotic symptoms
when mood is normal for a diagnosis of schizophrenia, whereas psychotic
symptoms must remit for a diagnosis of major mood disorder.
Treatment Considerations for PTSD Comorbidities 427

This section focuses primarily on PTSD comorbidity with schizophre-

nia and bipolar disorder. However, some attention will be given to the more
broadly defined group of people with severe mental illness (SMI), typically
defined as those having a major mental health disorder (schizophrenia, bipo-
lar disorder, major depression) that has a profound and persistent impact on
psychosocial functioning in areas such as ability to fulfill role functions (e.g.,
work, school, parenting), participation in social relationships, and indepen-
dent living and self-care. The relevance of the broader SMI category to the
topic of PTSD comorbidity is that, despite high rates of comorbidity, indi-
viduals with SMI have historically been excluded from PTSD treatment trials
based on narrow study exclusion criteria (e.g., psychotic symptoms, cognitive
impairments, suicidal ideation), and because most trials have not been con-
ducted at community mental health centers where persons with SMI receive
their treatment.
There is ample evidence that schizophrenia and bipolar disorder
are both associated with increased rates of comorbid PTSD. Three meta-­
analyses indicate rates of PTSD in schizophrenia of 12.4–29% (Achim et
al., 2011; Buckley, Miller, Lehrer, & Castle, 2009; Zammit et al., 2018), and
one meta-­analysis of bipolar disorder reported a 16% rate of comorbidity
with PTSD (Otto et al., 2004). Even higher rates of PTSD comorbidity have
been reported in inpatient and outpatient samples of persons with SMI,
with most reports ranging between 25 and 50% (Grubaugh, Zinzow, Paul,
Egede, & Frueh, 2011; Mueser et al., 1998), but with low levels of comorbid-
ity documented in patients’ charts. Thus, PTSD is a common but frequently
undetected comorbid disorder in people with these disorders (Zammit et
al., 2018).
A variety of reasons may account for the high comorbidity of PTSD with
schizophrenia and bipolar disorder. First, in addition to increasing the risk
of developing PTSD, exposure to traumatic events in childhood increases
vulnerability to the development of psychotic symptoms and illness (Varese
et al., 2012) and the broad range of mental health disorders in adulthood
(Carr, Martins, Stingel, Lemgruber, & Juruena, 2013), including schizophre-
nia (Husted, Ahmed, Chow, Brzustowicz, & Bassett, 2012; Matheson, Shep-
herd, Pinchbeck, Laurens, & Carr, 2013) and bipolar disorder (Etain, Henry,
Bellivier, Mathieu, & Leboyer, 2008). Thus, trauma may serve as a “third
variable” increasing vulnerability to both PTSD and psychotic disorders.
Second, the diagnosis of PTSD is predictive of subsequent hospitalization
and treatment for schizophrenia and bipolar disorder (Okkels, Trabjerg,
Arendt, & Pedersen, 2017), suggesting that the stress associated with PTSD
may trigger the onset of psychotic symptoms for some. Third, individuals
with schizophrenia are more likely to be traumatized and interpersonally
victimized in the community after developing their mental illness (Desma-
rais et al., 2014; Maniglio, 2009), thereby increasing their risk of develop-
ing PTSD. Fourth, there is evidence for shared genetic vulnerability to the
development of PTSD and schizophrenia and bipolar disorder (Duncan et
428 Application, Implementation, and Future Directions

al., 2018). Fifth, psychotic symptoms may occur secondary to PTSD (Seow et
al., 2016; Shevlin, Armour, Murphy, Houston, & Adamson, 2011), leading to
the possible misdiagnosis of PTSD as a psychotic disorder.
The treatment of PTSD in people with schizophrenia and bipolar disor-
der has lagged far behind treatment advances for the primary PTSD popu-
lation, for two primary reasons. First, some clinicians believed that reports
of patients with psychotic symptoms about their traumatic experiences and
PTSD symptoms were unreliable, and likely to reflect distorted or delusional
thinking. Contrary to this concern, research has shown that the assessment
of trauma history and PTSD symptoms with standardized measures yields
reliable and valid diagnoses of PTSD in patients with SMI (Meyer, Muenzen-
maier, Cancienne, & Struening, 1996; Mueser et al., 2001). Second, some
clinicians were concerned that the assessment of trauma history and PTSD
could be upsetting to people with psychotic symptoms, and that the stress
of trauma-­based treatment of PTSD could precipitate relapse of symptoms.
Early efforts to assess trauma and PTSD in persons with schizophrenia and
bipolar disorder found no basis for these concerns, nor did early work on
treatment.
Interest in treating PTSD in persons with schizophrenia and bipolar dis-
order emerged out of a growing awareness of the high prevalence of undiag-
nosed PTSD in this population (Cusack, Grubaugh, Knapp, & Frueh, 2006),
coupled with research suggesting that PTSD contributes to a worse course of
the illness (Mueser, Rosenberg, Goodman, & Trumbetta, 2002). The impor-
tance of this work was amplified in a review of 34 published RCTs of PTSD
treatment for adults that found severe comorbid psychopathology was the
single most common reason for excluding patients from studies, and called
for research on treatments for PTSD that were flexible and could be adapted
to characteristics of those patients most likely to have the disorder (Spinaz-
zola, Blaustein, & van der Kolk, 2005). In the intervening years, growing evi-
dence has supported the feasibility and beneficial effects of treating PTSD
in people with schizophrenia and bipolar disorder.
Several research groups have evaluated the delivery of established treat-
ment methods for PTSD in the general population to individuals with schizo-
phrenia and/or bipolar disorder. Mueser, Rosenberg, and Rosenberg (2009)
developed a 12- to 16-session individual program for vulnerable populations
with PTSD, based primarily on cognitive restructuring, but also including
psychoeducation about PTSD and breathing retraining. After demonstrat-
ing the safety, feasibility, and clinical promise of the intervention in an
uncontrolled trial (Rosenberg, Mueser, Jankowski, Salyers, & Acker, 2004),
the program was evaluated in two RCTs of persons with SMI and PTSD. The
first trial compared the cognitive restructuring program with usual services
in 108 patients with SMI (39% schizophrenia or bipolar), and found sig-
nificantly greater improvements in PTSD and depression at the end of treat-
ment, with gains maintained at 3- and 6-month follow-­ups (Mueser et al.,
2008). The second RCT compared the full cognitive restructuring program
Treatment Considerations for PTSD Comorbidities 429

with just the psychoeducation and breathing retraining components deliv-

ered over three sessions in 201 patients with SMI (68% schizophrenia or
bipolar) and PTSD (Mueser et al., 2015). Patients in the cognitive restruc-
turing program improved more than those in the brief program in PTSD
symptoms and psychosocial functioning (both groups improved similarly in
depression), with gains maintained at 6- and 12-month follow-­ups. In nei-
ther study was there a significant treatment group by diagnosis interaction,
indicating that people with schizophrenia and bipolar disorder benefited as
much from the cognitive restructuring program as those with major depres-
sion. A third small RCT compared the cognitive restructuring program with
usual treatment in 61 patients with schizophrenia and PTSD. Both groups
of patients showed significant improvements in PTSD symptoms, but there
were no differences between the groups (Steel et al., 2017). An important
difference between this third study and the previous two studies was that
the patients had less severe PTSD symptoms, suggesting that the benefits
of the cognitive restructuring program may be strongest for persons with
schizophrenia or bipolar disorder with more severe PTSD.
Some research also supports the feasibility and beneficial effects of
evidence-­based exposure therapy and EMDR therapy in patients with schizo-
phrenia. Frueh, Grubaugh, and colleagues developed a treatment model for
patients with schizophrenia-­P TSD that combines social skills training and
exposure therapy (Frueh et al., 2009), and it has been shown to be feasible
and associated with improvements in PTSD and related outcomes in two
uncontrolled clinical trials (Frueh et al., 2009; Grubaugh et al., 2016). Van
den Berg and colleagues (2015) conducted an RCT comparing a nine-­session
exposure therapy program with a nine-session EMDR therapy program,
with usual services in 151 patients with schizophrenia-­P TSD, and found
greater reductions in PTSD symptoms within both active treatment groups,
which were maintained at 6-month follow-­up. Furthermore, patients who
received either of the trauma-­focused interventions were significantly less
likely to experience symptom exacerbations, adverse events, or revictimiza-
tion (van den Berg et al., 2016), suggesting that delaying trauma-­focused
treatment could actually expose patients to worse clinical and psychosocial
outcomes. Together, these studies provide preliminary evidence that PTSD
can be treated in people with comorbid schizophrenia or bipolar disorder,
and that trauma-­focused interventions with this population are both safe
and effective.

Borderline Personality Disorder

Borderline personality disorder (BPD) has been conceptualized by some to
have its origins in early life traumatic experiences and to overlap with PTSD
(Gunderson & Sabo, 1993; McLean & Gallop, 2003). Several studies have
found that BPD is particularly associated with childhood abuse and neglect
(see Cattane, Rossi, Lanfredi, & Cattaneo, 2017), although childhood trauma
430 Application, Implementation, and Future Directions

is not universally reported and biological vulnerabilities and neurobiologi-

cal processes have also been found to be important to the development of
BPD. Research indicates high rates of PTSD comorbidity in patients with
BPD, ranging from 25 to 56% (see Golier et al., 2003; Mueser et al., 1998;
Pagura et al., 2010). However, despite the high comorbidity of these two
disorders, only limited research has examined the treatment of PTSD in
patients with BPD.
Historically, the high level of affective instability in patients with BPD,
their low tolerance for negative emotions, and in particular the parasuicidal
and self-­injurious behavior patterns that characterize the disorder have dis-
couraged clinicians from attempting to treat comorbid PTSD for fear of
worsening these behaviors and increasing the risk of a completed suicide.
The prevailing clinical approach to BPD, dialectical behavior therapy (DBT;
Linehan, 1993), has been to focus initial treatment on teaching personal self-­
management and social skills to reduce parasuicidal and self-­injurious behav-
iors, regardless of whether comorbid PTSD is also present. More recently
along these lines, a formal stage model was developed for treating people
with BPD and PTSD over a 1-year period, in which DBT is implemented first
in order for the patient to achieve a sufficient level of self-­control, and then
followed by PE (Harned, Korslund, Foa, & Linehan, 2012). A small (N = 27)
pilot RCT in patients with BPD and PTSD comparing DBT with DBT plus PE
reported that 59% of patients assigned to the staged treatment completed the
treatment, and that patients in the staged group had better PTSD outcomes
than those who received DBT alone (Harned, Korslund, & Linehan, 2014).
Two RCTs of trauma-­focused PTSD treatments in general population
samples have explored whether patients with PTSD and BPD benefit less
from treatment than those with PTSD only. In an RCT of 72 rape survivors
with PTSD randomized to PE, stress inoculation (SI), PE + SI, or wait-list
control, the outcomes of 12 women who met criteria for BPD or partial BPD
were explored (Feeny, Zoellner, & Foa, 2002). The general observation was
that the patients with PTSD and BPD (or partial BPD) benefited from the
treatments, but the sample size prevents definitive conclusions. A second
RCT compared the effectiveness of PE and CPT in 131 rape victims with
PTSD who were also administered a self-­report measure of BPD at base-
line (Clarke, Rizvi, & Resick, 2008). Patients with higher scores on the self-­
reported BPD measure had more severe PTSD symptoms than those with
PTSD alone but did not differ in rates of dropout from treatment or in ben-
efit from treatment. This study suggests that women with BPD-PTSD may
benefit from trauma-­focused treatment, although it is limited by self-­report
measurement of BPD.
Finally, the results from two RCTs of the cognitive restructuring pro-
gram for PTSD in special populations (Mueser et al., 2009) have bearing
on the effects of trauma-­focused treatments on patients with BPD. The two
RCTs described in the previous section included patients with SMI-PTSD
and compared the cognitive restructuring program in the first study with
Treatment Considerations for PTSD Comorbidities 431

treatment as usual (TAU; Mueser et al., 2008) and in the second study with
a brief (three-­session) intervention (Mueser et al., 2015). In addition to meet-
ing criteria for SMI and PTSD, participants were also evaluated at baseline
for BPD with the SCID-II, with 27/108 (25%) and 55/201 (27%) meeting
criteria for BPD, respectively. Of note, at baseline, nearly 60% of patients
in both samples endorsed recently having suicidal thoughts (Kredlow
Acunzo et al., 2017). Separate analyses of the patients with BPD indicated
that in both studies those who received cognitive restructuring had greater
improvements in PTSD symptoms and diagnosis than the usual treatment
group, who actually worsened over the treatment period in general psychiat-
ric symptoms in Study 1 (Kredlow Acunzo et al., 2017). Across both studies,
rates of PTSD symptom exacerbation for patients with BPD in the cognitive
restructuring group were very low (Kredlow Acunzo et al., 2017), suggesting
the trauma-­focused intervention was tolerated well by this group.
Taken together, the findings provide some evidence that patients with
PTSD-BPD can safely participate in trauma-­focused treatment, and that
receipt of such treatment is associated with improvements in PTSD and
related outcomes.

Chronic Pain
Chronic pain is one of the most commonly reported problems for people
with PTSD (Sharp & Harvey, 2001). Individuals with chronic pain result-
ing from a variety of pathologies frequently present with PTSD symptoms
(Asmundson, Coons, Taylor, & Katz, 2002; Sharp & Harvey, 2001). High
levels of chronic pain have been found especially among some populations
with PTSD, such as veterans (Fishbain, Pulikal, Lewis, & Gao, 2017), tor-
ture survivors (Dibaj, Halvorsen, Kennair, & Stenmark, 2017), and refugees
(Rometsch-­Ogioun El Sount et al., 2019). Two systematic reviews (Brennen-
stuhl, Tarquinio, & Montel, 2015; Fishbain et al., 2017) found PTSD rates
far higher than in the general population for most pain types. Other work
has pointed to frequent reporting of childhood abuse in some chronic pain
populations (Coppens et al., 2017).
There is evidence from several sources that the co-­ occurrence of
chronic pain and PTSD has a major impact on the evolution of both disor-
ders (Asmundson, 2014; Asmundson et al., 2002). The presence of pain is
associated with poorer treatment outcomes in some populations, although
the treatment literature for co-­occurring PTSD and chronic pain is very lim-
ited (Asmundson, 2014). Clinical experience suggests that some patients will
avoid trauma-­focused therapy for fear of exacerbating their pain. The use
of analgesics has been found to be particularly high in PTSD sufferers, com-
pared to other mental health disorders (Schwartz et al., 2006).
Pain is recognized as a complex phenomenon involving biological,
psychological, and social factors (Asmundson et al., 2002; Brennenstuhl
et al., 2015). PTSD and chronic pain share some overlapping features
432 Application, Implementation, and Future Directions

(e.g., heightened anxiety, hypervigilance and attentional bias for poten-

tial threats, avoidance behaviors) and some vulnerabilities such as anxiety
sensitivity (Asmundson, 2014; Asmundson et al., 2002; Bosco, Gallinati, &
Clark, 2013). Pain and PTSD are also thought be involved in mutual main-
tenance (Asmundson et al., 2002; Bosco et al., 2013). Pain can represent a
trauma cue, acting as a reminder of the traumatic experience. Pain is also
emotionally distressing and may aggravate hyperarousal symptoms, which
are, in turn, associated with muscular tension and spasms, contributing to
increased pain and leading to a “self-­perpetuating vicious cycle” (Asmund-
son, 2014). Pain can also feature as a sensory component of reexperiencing
(Bosco et al., 2013). As a result, chronic pain sufferers are likely to avoid
pain triggers, which inhibits natural processing of trauma memories. There
is some research to suggest that PTSD influences the perception of pain,
such that individuals with PTSD experience greater pain severity and report
more pain complaints (see Fishbain et al., 2017).
In routine practice, clinicians from a mental health background often
fail to screen for chronic pain (Asmundson, 2014). Clinicians treating indi-
viduals with PTSD should ensure that they investigate for co-­occurring pain
symptoms with the aim of understanding their relationship to PTSD symp-
toms (Asmundson et al., 2002; Asmundson & Hadjistavropolous, 2006; Fish-
bain et al., 2017). Key aspects of pain that clinicians should explore include
pain intensity and location, patient beliefs and attitudes in relation to their
pain, patterns of coping, pain-­related emotional distress, and resulting phys-
ical limitations (Asmundson & Hadjistavropolous, 2006). Similarly, trauma
history and PTSD symptoms should be screened for on a routine basis in
chronic pain settings (Coppens et al., 2017). Cognitive-­behavioral interven-
tions for pain and PTSD share some common features. Reduction of cogni-
tive and behavioral avoidance, via exposure, and aiming to increase activ-
ity levels are central to the treatment of both conditions (Sharp & Harvey,
2001). When the two disorders co-occur, it is important to help the patient
understand how they are connected and to consider whether treatment
needs to be adapted to enhance engagement and address maintaining cycles
(Asmundson et al., 2002). The treatment literature for co-­occurring PTSD
and chronic pain is very limited. There is some indication that chronic pain
can interfere with engagement in trauma-­focused therapy but also some work
suggesting that many individuals can improve with PTSD therapy (Asmund-
son, 2014). To date, there is no evidence that CBT for pain management has
any significant impact on PTSD symptoms (Asmundson, 2014). Very little
literature exists on distinctive models of treatment for PTSD-­chronic pain
comorbidity (Asmundon, 2014; Brennenstuhl et al., 2015). Some experts
in the field (e.g., Asmundson, 2014; Otis, Keane, Kerns, Monson, & Scioli,
2009) have suggested that integrated PTSD and pain approaches might be
helpful for many patients. Potential common components of integrated ther-
apy may include psychoeducation, cognitive restructuring, emotion regula-
tion strategies such as progressive muscle relaxation, in vivo and graded
Treatment Considerations for PTSD Comorbidities 433

in vivo exposure, activity planning, and weight training (Asmundon, 2014;

Bosco et al., 2013). Data evaluating such approaches are very limited. Some
very preliminary work suggests the potential benefit of co-­delivered exercise
and physiotherapy, in conjunction with trauma-­focused therapy (Dibaj et al.,
2017; Manger & Motta, 2005). Otis and colleagues (2009) developed a pilot
integrated model incorporating components of CPT for PTSD with CBT for
pain management, but this is yet to be tested in a comparison study. Further
research into interventions that might improve this comorbidity is clearly
required.

Addressing Comorbidity in Children

and Adolescents

Although clinicians are often less concerned with establishing specific diag-
nostic status for child and adolescent populations than for adults, comorbid-
ity is also the rule. A clear sign of this is the common reference to either
overall “internalizing” or “externalizing” symptoms in children and adoles-
cent populations. Research reports high rates of comorbidity for childhood
anxiety disorders, which could include PTSD, generalized anxiety disorder
(GAD), specific and social phobia, panic disorder, and obsessive–­compulsive
disorder. Studies have shown overlap with depression (17–69%), external-
izing disorders (8–69%), attention-­deficit hyperactivity disorder (ADHD),
oppositional defiant disorder (ODD), and conduct disorder (CD) (Angold,
Costello, & Erkanli, 1999). Studies of children and adolescents show that
exposure to traumatic events, especially violence and polyvictimization, and
PTSD diagnoses are associated with behavior problems and SUDs (e.g., Car-
liner et al., 2016; Moffitt & Caspi, 2001). Maltreatment and interpersonal
violence experiences in childhood are consistently associated with external-
izing problems in children and adolescents (e.g., Dube et al., 2006; Widom,
Schuck, & White, 2006) with estimated prevalence rates of ODD, CD, and
SUD two to four times higher in trauma-­exposed populations, relative to
those with no exposure and higher rates following exposure to interper-
sonal violence (Carliner, Gary, McLaughlin, & Keyes, 2017; Lubman, Allen,
Rogers, Cementon, & Bonomo, 2007). Comorbidity is often associated with
increased symptom variation, severity and impairment, more frequent and
severe negative correlates and sequelae, differential treatment response, and
distinct courses (Ollendick, Jarrett, Grills-­Taquechel, Hovey, & Wolff, 2008).
Trauma-­ focused cognitive-­behavioral therapies and EMDR therapy
have the strongest evidence base for children and adolescents with PTSD
(see Kenardy, Kassam-­Adams, & Dyb, Chapter 10, and Jensen, Cohen, Jay-
cox, & Rosner, Chapter 21, this volume). Given the frequent comorbidity
found in trauma-­exposed children and adolescents, many studies evaluating
PTSD treatments measure both internalizing and externalizing symptoms.
In a review by Silverman and colleagues (2008), two interventions were
434 Application, Implementation, and Future Directions

determined to be effective for symptoms of PTSD, depression, anxiety, and

externalizing behavior problems: trauma-­focused cognitive-­behavioral ther-
apy (TF-CBT; for further information, go to www.musc.edu/tfcbt) and Cogni-
tive Behavioral Intervention for Trauma in Schools (CBITS). TF-CBT has the
most extensive evidence of effectiveness for children and adolescents with
trauma-­related symptoms, with multiple RCTs, longer-­term follow-­up (12
months out), and a large number of quasi-­experimental studies (see Dorsey,
Briggs, & Woods, 2011, for a review). TF-CBT also has been evaluated in
trials in low- and middle-­income countries, showing strong effectiveness
even when delivered by lay providers without formal mental health training
(Murray et al., 2015). Evidence of reduced PTSD symptoms has also been
reported for CBITS in one RCT and two uncontrolled studies (see Dorsey
et al., 2011, for a review). Ollendick and colleagues (2008) examined comor-
bidity and its potential effects on treatment outcomes of focal EBTs. The
authors concluded that, although many treatment studies with children and
adolescents included comorbid samples, very few studies examined whether
comorbidity was a moderator of treatment outcome.

Transdiagnostic Interventions

Addressing comorbidity, from the perspectives of public health, efficiency,

and implementation science (e.g., Martin, Murray, Darnell, & Dorsey, 2018),
has led to growing interest and research in transdiagnostic treatments for
children, adolescents, and adults. Transdiagnostic approaches are those
that aim to address multiple problem areas or diagnoses. In the early 2000s,
researchers hypothesized the ability for one focal treatment to alleviate
symptoms of a comorbid disorder—­suggesting that some of the processes
that maintain one disorder also maintain comorbid disorders (Mansell et
al., 2009; Tsao, Mystkowski, Zucker, & Craske, 2005). Researchers have cited
a number of potential advantages of transdiagnostic treatment approaches,
such as more efficient training and dissemination, reduced training costs for
organizations, improved fit for comorbid presentations, and better clinician
and client satisfaction (e.g., Mansell et al., 2009; Marchette & Weisz, 2017).
A number of transdiagnostic approaches have now been developed (see
Boustani, Gellatly, Westman, & Chorpita, 2017) and evaluated compared to
disorder-­specific treatments. Transdiagnostic approaches are designed in a
number of different ways. For example, some models utilize the same ele-
ments conceptualizing comorbidities as resulting from a shared mechanism
(e.g., the Unified Protocol for the Treatment of Emotional Disorders [UP];
Barlow et al., 2017). A variation on these models is a modular treatment,
which chooses and prioritizes different elements depending on the symp-
tom/problem presentation (e.g., Modular Approach to Therapy for Children
with Anxiety, Depression, Trauma, or Conduct Problems [MATCH-ADTC];
Chorpita & Weisz, 2009).
Treatment Considerations for PTSD Comorbidities 435

UP is a transdiagnostic treatment based on the shared mechanisms

approach, targeting a range of anxiety and mood disorders in adults (Bar-
low et al., 2017). The shared underlying mechanism targeted by UP is the
biologically based propensity to experience strong negative emotions. UP
includes elements on increasing tolerance of negative emotions, decreasing
avoidant coping that maintains negative emotional experiences, and teach-
ing patients more adaptive ways to respond to negative emotions. UP has
shown strong effectiveness across depression and anxiety disorders through
multiple trials (Barlow et al., 2017; Farchione et al., 2012). In the large 2017
RCT (N = 223), UP had treatment equivalence with disorder-­specific treat-
ment protocols for four anxiety disorders on severity of principal diagnosis
at the end of treatment and a 6-month follow-­up (Barlow et al., 2017). UP
has shown effectiveness for panic disorder along with other mood and emo-
tional disorders, including PTSD (Barlow et al., 2017; Farchione et al., 2012).
Focused in low- and middle-­income countries globally, the Common Ele-
ments Treatment Approach (CETA; Murray et al., 2014) has been evaluated
in three published RCTs with populations who have experienced trauma, and
two additional RCTs that have been completed (Bolton et al., 2014; Bonilla-­
Escobar et al., 2018; Weiss et al., 2015). CETA is a cognitive-­behavioral,
modular, flexible, multiproblem transdiagnostic treatment model that was
developed based on advances in high-­income settings and built for imple-
mentation in low- and middle-­income countries with lay providers. Trau-
matic stress symptoms could be a key focus of treatment in CETA through
cognitive and exposure-­based elements. On the Thailand/Myanmar border,
CETA’s effect sizes (Cohen’s d) were strong for improving depression (d =
1.16) and posttraumatic stress (d = 1.19). In Iraq, there were large effect
sizes for improving depression (d = 1.78) and posttraumatic stress (d = 2.38;
Weiss et al., 2015). In Iraq, CETA outperformed two disorder-­specific treat-
ments: behavioral activation for depression and CPT for trauma (Bolton et
al., 2014).
For children and adolescents, Chorpita and colleagues introduced the
idea of common practice elements within different focal treatments with the
Distillation and Matching Model (DMM; Chorpita, Daleiden, & Weisz, 2005).
They went on to develop the Modular Approach to Therapy for Children
with Anxiety, Depression, Trauma, or Conduct Problems (MATCH-ADTC),
which is the most evaluated transdiagnostic approach in the United States.
MATCH-ADTC addresses high-­ prevalence clusters of problems among
children and adolescents from 6 to 15 years of age, including PTSD, which
include elements such as exposure (Chorpita & Weisz, 2009). The effective-
ness of MATCH-ADTC over both usual care and disorder-­specific treat-
ments has been established through two large RCTs in community settings
(Chorpita et al., 2017; Weisz et al., 2012), with effects maintained at 2-year
follow-­up (Chorpita et al., 2013). Compared to usual care, MATCH-ADTC
was associated with shorter treatment duration, lower use of other mental
health services, and lower rates of psychotropic medication use. Another
436 Application, Implementation, and Future Directions

transdiagnostic model for children and adolescents is principle-­ g uided,

which focuses on the principles of therapeutic change that underlie com-
mon procedures (Weisz & Bearman, 2020). This approach was only recently
introduced and is in the early stages of testing (Weisz, Bearman, Santucci,
& Jensen-­Doss, 2017). UP was recently adapted for adolescents and children
(Ehrenreich-­May et al., 2017) and is also based on a core dysfunction or
maintaining process that leads to multiple problems or disorders (Barlow et
al., 2017). This approach shows promise for children and young people, with
clinical several effectiveness trials under way. CETA (Murray et al., 2014) has
been evaluated for children and adolescents living in refugee camps in East
Africa in an open trial and showed significant reductions in externalizing
and internalizing symptoms, and PTSD (Murray et al., 2018).
Additional studies are warranted on transdiagnostic models from dif-
ferent approaches (shared mechanism, common elements, and principle-­
guided), perhaps specifically to compare disorder-­ specific treatments’
impact on comorbid problems with that of emerging transdiagnostic mod-
els.

Conclusions
Clinical Considerations
The presence of comorbidity presents a challenge to clinicians, research-
ers, and providers. This chapter presents evidence establishing that trauma-­
focused therapies can be effective for PTSD with a number of comorbidi-
ties, although manualized interventions may sometimes require adaptation.
Increasingly, evidence favors combined/integrated approaches for SUD
comorbidity, with some support for similar approaches with other comorbid-
ities such as chronic pain and panic disorder. For children and adolescents,
transdiagnostic approaches are being increasingly advocated. From a clinical
standpoint, thorough screening and assessment of comorbidities are clearly
key to good treatment planning. Clinicians should seek to elicit a detailed
history of the unfolding of symptoms both pre- and post-event (Lockwood
& Forbes, 2014) so that they can fully understand the relationship between
events, symptom development, and maintaining factors to formulate a treat-
ment plan appropriate to the patient’s needs. In many cases, it should be
possible to treat patients with many comorbidities successfully—­sometimes
with minor adaptations to existing treatment protocols. However, in cases
of severe comorbidity, clinicians should consider integrated or concurrent
treatment.
The realities of clinical practice are that many patients present for
help with multiple comorbidities, often alongside related clinical problems,
such as relationship problems, problematic anger, interpersonal violence
perpetration, parenting issues, housing problems, and employment-­related
difficulties. In complex cases, it can be difficult to decide what problems
Treatment Considerations for PTSD Comorbidities 437

should be prioritized, and sometimes addressing conditions such as PTSD

may not be the immediate concern. For those with complex needs, a case
management approach is often required to plan and coordinate a response
to primary needs. For some individuals, a period of building a trusting
relationship with a service or team may be an important foundation for
engagement with EBTs (Holdsworth, Bowen, Brown, & Howat, 2014; Kehle-­
Forbes & Kimerling, 2017). Ambivalence about engaging in trauma-­focused
therapy is a significant issue in the field, even for those without significant
comorbidities (Kehle-­Forbes & Kimerling, 2017). Psychoeducation and moti-
vational interventions are often an important part of the engagement pro-
cess, although evidence of the benefits of interventions aimed at enhancing
motivation to engage in EBTs is mixed (Kehle-­Forbes & Kimerling, 2017).
Figure 22.1 identifies some of the key principles of treatment planning when
multiple comorbidities are indicated.

• PTSD sufferers should be screened for common comorbidities on a routine

basis, with further detailed assessment as indicated.
• PTSD is a common comorbidity with many other disorders and should be
screened for in all mental health settings.
• Clinicians should routinely develop a biopsychosocial case formulation (e.g.,
Lee, 2016) to support their understanding of the development and maintenance
of PTSD and comorbid conditions. Particular attention should be given to
precipitating factors, current stressors and triggers, and mutual maintaining
factors and cycles of symptom interaction.
• Clinicians should not exclude patients with a diagnosis of psychotic disorders,
substance use disorders, and borderline personality disorders from trauma-
focused psychological therapy. Readiness to engage in evidence-based
treatment should be evaluated on an individual basis.
• Intervention should be guided by current evidence.
• High-risk concerns should normally be the priority for intervention.
• Psychoeducation adapted to the individual’s level of comprehension is often
an important component of engagement. Promoting an understanding of the
relationship between PTSD and other relevant comorbidities can also help the
engagement process.
• During the assessment process, clinicians should consider whether comorbid
disorders and symptoms are likely to obstruct engagement in trauma-focused
therapy and consider offering concurrent interventions, such as COPE or M-CET,
when indicated.
• When significant comorbidities are present, clinicians should consider
evidence‑based interventions that may address common cycles of symptom
maintenance.
• When therapeutic blocks occur, clinicians should reformulate.

FIGURE 22.1. Principles for treating PTSD and comorbidities.

438 Application, Implementation, and Future Directions

Future Research
From the current treatment literature, it is unclear to what extent comorbidi-
ties such as depression, panic disorder, and chronic pain impede the success
of EBT for PTSD. To better understand the impacts of comorbidities, it would
be helpful if future treatment trials could investigate comorbidity effects and
report outcomes by comorbidity so that data can be aggregated across stud-
ies to establish clearer comorbidity effects. Outcomes for co-­occurring con-
ditions should be evaluated throughout the course of treatment (Teng et al.,
2013). Future studies would need to be adequately powered and resourced
to achieve this goal. Reporting of this kind would also help to give a clearer
understanding of the need for integrated approaches (Asmundson, 2014;
Stander et al., 2014). Although this chapter focused on mental health disor-
ders as comorbidities, continued research is necessary to identify and target
other co-­occurring clinical problems such as anger, interpersonal violence
perpetration, intimate relationship and parenting problems, and difficulties
returning to work (Monson & Fredman, 2012; Stergiopoulos, Cimo, Cheng,
Bonato, & Dewa, 2011; Taft, Creech, & Murphy, 2017).
In future work, it will be helpful to identify critical treatment mecha-
nisms that may mediate outcomes across disorders (Stander et al., 2014).
Future research must also seek to identify modifiable risks and vulner-
abilities, which might be targets for prevention and treatment approaches
(Stander et al., 2014). In this vein, anxiety sensitivity has been indicated as a
vulnerability factor for both panic disorder and chronic pain (Asmundson,
2014; Teng et al., 2013), and interventions aimed at reducing anxiety sensitiv-
ity may merit further exploration as a possible early psychological interven-
tion or in conjunction with established treatments. Finally, although there
is evidence of the benefits of transdiagnostic approaches for young people,
such approaches have not been given as much attention in the adult PTSD
literature, despite some evidence of their benefit in trauma-­exposed popula-
tions living in low- and middle-­income countries (Bolton et al., 2014; Weiss
et al., 2015). Transdiagnostic approaches may be beneficial in addressing
underlying shared core vulnerabilities in PTSD and its comorbidities (Gut-
ner, Galovski, Bovin, & Schnurr, 2016) and should therefore be investigated
further.

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C H A P TE R 23

Building a Science of Personalized

Interventions for PTSD
Marylene Cloitre, Zachary Cohen, and Ulrich Schnyder

Tthehis chapter is dedicated to exploring “next steps” in improving treatment

outcomes for people with posttraumatic stress disorder (PTSD). Over
past decade, there has been growing attention to the development of
personalized interventions to improve treatment response rates. Personalized
interventions consider at least three factors for the refinement and tailoring
of treatment: the individual patient, his or her specific problem, and the
particular set of circumstances under which the individual is treated. This
idea was proposed by psychotherapy researchers over a half-­century ago
(e.g., Luborsky, Crits-­Christoph, Mintz, & Auerbach, 1988; Paul, 1967), but
the methodological and statistical means by which to reach this goal were
lacking. More recently, there have been advances in the conceptualization
of personalized interventions along with advances in research and analytic
methods that are likely to allow this goal to be realized.
This chapter reviews several evolving strategies for personalizing mental
health interventions that are relevant to the treatment of PTSD. These include
adaptation of treatments for specific populations and environments, modu-
lar therapies, sequential multiple assignment randomized trials (SMART),
and individualized metrics. We also report on the literature regarding per-
sonalized treatments in the context of neurobiological findings.

Therapies Adapted for Specific Populations

and Environments

The most common example of adaptations of evidence-­ based therapies

(EBTs) lies in their application to different cultures. Because most EBTs have
been developed and tested mainly with Caucasian and Western samples,

451
452 Application, Implementation, and Future Directions

the concepts and examples used in the treatments may not be relevant to
and are potentially discordant with other cultures. Adaptations may involve
not only a translation to a different language but also reformulation of the
treatment to attend to culturally relevant trauma-­related experiences and
concepts as well as reformulation of the interventions themselves so that the
treatment is consistent with the patient’s experience and perspective (Ber-
nal, Jimenez-­Chafey, & Domenech Rodriguez, 2009; Hinton, Field, Nicker-
son, Bryant, & Simon, 2013).
To date, most adaptations have been developed for culturally distinct
subgroups of a population of interest. The process by which adaptations are
made typically involves collaboration with providers, patients, and commu-
nity stakeholders to assess the content validity of the treatment, to revise the
treatment, and to engage in iterative modifications throughout the initial
delivery of the protocol (Dixon, Ahles, & Marques, 2016; Hinton, Rivera,
Hofmann, Barlow, & Otto, 2012).
The most conservative study design assesses whether the cultural
adaptation of the protocol confers added benefit relative to the standard
approach. Evaluations using this type of design with regard to adaptations
of cognitive-­behavioral therapy (CBT) for Latino populations in the United
States have found mixed results, with benefit associated only with some adap-
tations depending on the specific treatment, type of problem, and strength
of identification with the subculture (Ng & Weisz, 2016). The results thus far
suggest that culturally sensitive perceptions of mental health disturbances as
well as their solutions vary from subgroup to subgroup and from culture to
culture, indicating the importance of utilizing qualitative data derived from
multiple sources to formulate adaptations and of developing reliable means
by which to make generalizations (see Riggs et al., Chapter 24, this volume,
on implementation science).
Several recent studies of traumatized populations have described col-
laborative processes between researchers and stakeholders who represent
minority populations or cultures different from the researchers to develop
more appropriate and effective engagement strategies, assessment measures,
and therapies (e.g., Kaysen et al., 2013; Tay & Silove, 2017; Valentine, Dixon,
Borba, Shtasel, & Marques, 2016), providing good examples of implementa-
tion science principles. Clinical trials have evaluated the feasibility and effi-
cacy of adapted cognitive-­behavioral therapies relative to wait list or treat-
ment as usual in several non-­Western cultures. Probably the most well-­studied
intervention used in non-­ Western settings is narrative exposure therapy
(NET). NET was initially developed by Western clinician-­researchers mainly
using “Western” cognitive-­behavioral concepts to address PTSD in African
refugees. A number of randomized controlled trials (RCTs) have successfully
been conducted in a variety of cultural settings, demonstrating NET’s effec-
tiveness in both Western and non-­Western countries (e.g., Hijazi et al., 2014;
Neuner, Schauer, Klaschik, Karunakara, & Elbert, 2004; Neuner et al., 2008).
At least three adaptations of cognitive processing therapy (CPT) have
been tested in RCT designs (Bass et al., 2013; Bolton et al., 2014; Weiss et al.,
Building a Science of Personalized Interventions for PTSD 453

2015). As an example of the adaptation of CPT for the Kurdish population

in Iraq, initial review indicated that two traditional CPT themes considered
related to trauma, impact on self- ­esteem and intimacy, did not have a direct
translation in the Kurdish language, so alternative themes of respect and car-
ing were identified and used in the treatment. The adapted version of CPT
was found to show moderate to strong effect sizes relative to wait list on
depression, posttraumatic stress symptoms, and dysfunction (Bolton et al.,
2014). A similar process of adaptation has been applied to trauma-­focused
cognitive-­behavioral therapy (TF-CBT) for delivery to Congolese female ado-
lescent victims of sexual violence. Adaptations included the use of familiar
games and songs to convey concepts and visits to the girls’ guardians, with the
goal of reducing the family’s perception of stigma and fostering family accep-
tance of and reconnection with the victim. Results of an RCT comparing TF-
CBT to wait list found that the treatment group reported significant reduc-
tions in trauma symptoms and increased prosocial behavior (O’Callaghan,
McMullen, Shannon, Rafferty, & Black, 2013). Both of these studies indicate
that an evidence-­based treatment can successfully be adapted to very dif-
ferent cultures. There have been several other evidence-­based interventions
that demonstrated successful adaptation to other cultures, including an open
trial of eye movement desensitization and reprocessing (EMDR) therapy in
the Congo (Allon, 2015) and behavioral activation treatment for depression
among Kurds in Northern Iraq (Bolton et al., 2014).
Several questions can be posed when considering the adaptation of
evidence-­based treatments across different environments. With regard to
any treatment, one might ask how much a specific therapy can be adapted
and still be considered the same treatment, or how many changes can be
made to a protocol before it becomes unrecognizable and evolves into
another treatment. These types of questions highlight the need for caution
regarding assumptions that the benefits in an adapted version will be simi-
lar to those of the established protocol. If an established treatment is sub-
stantially changed, the empirical evidence that provided the rationale for
the application of the treatment to the new population may no longer pro-
vide a credible basis for predictions of beneficial outcomes. An alternative
approach may be to identify the key common elements of effective trauma
treatments (see Schnyder et al., 2015) and to develop treatments based on
general principles of recovery instantiated in the language, idioms, beliefs,
and behaviors of the specific culture or population.

Modular Therapies

Modular therapies describe psychotherapies in which evidence-­based mod-

ules known to address and resolve specific problems are selected and orga-
nized to create a treatment plan tailored to a particular patient’s most signif-
icant symptoms and concerns. This approach reduces the risk of including
interventions and concepts that are not particularly relevant to the individual
454 Application, Implementation, and Future Directions

patient, potentially leading to greater willingness to engage in treatment,

better treatment attendance, increased use of interventions, and ultimately
better outcomes. The approach is particularly attractive considering the
potential heterogeneity of the symptom profiles of patients diagnosed with
DSM-5 PTSD or alternatively diagnosed with either PTSD or complex PTSD
(CPTSD) as delineated in the 11th revision of the International Classification
of Diseases and Related Health Problems (ICD-11). Moreover, it could be help-
ful in creating a streamlined treatment plan that is inclusive of the common
comorbid symptoms and disorders, such as depression, chronic pain, and
substance use. Thus, a modular therapy is an approach that can be conceptu-
alized as an efficient and effective way to address all and only the problems
presented by a particular patient.
Current treatment protocols offer a standardized sequence of interven-
tions, with treatment generally focusing on processing of the trauma mem-
ory (e.g., CPT, NET, prolonged exposure [PE], cognitive therapy for PTSD
[CT-PTSD]). Other therapies present or include resource-­building interven-
tions, such as social support enhancements, relationship strengthening, and
emotion regulation interventions (e.g., brief eclectic psychotherapy for PTSD
[BEPP], EMDR therapy, interpersonal therapy [IPT], skills training in affec-
tive and interpersonal regulation [STAIR] narrative therapy), and still others
that have been identified as relevant to commonly occurring comorbidities,
such as behavioral activation for depression, biofeedback for chronic pain,
and relapse prevention for substance use. In addition, the introduction or
integration of other types of interventions like medication, mindfulness, or
psychodynamic interventions can be considered. The specific interventions
or series of interventions to be selected for investigating a modular therapy
approach remain to be considered and may vary as different researchers
use protocols with which they are experienced as the reference or standard
treatment to which the modularized treatment will be compared.
The infrastructure supporting the implementation of flexible modular
therapies typically includes assessment measures and decision-­making flow-
charts (Chorpita & Weisz, 2009). The therapist and patient collaborate to
review the initial assessment results and to identify the primary problem;
this information is used, in turn, to select a module or series of modules for
the treatment plan. A critical aspect of the work is regular symptom assess-
ment, identifying progress made on target symptoms. The results of these
assessments guide next-step decision making about whether to repeat the
module, go on to the next planned module, or revise plans for the next mod-
ule if the secondary symptoms have resolved or new symptoms or problems
have emerged.
Relevant to this discussion is consideration of the potential benefits
of the flexible multimodular treatment approach broadly conceived and
evidence for its success. In studies of child and adolescent mental health
programming, the flexible sequencing of self-­contained modules has been
demonstrated to be more effective compared to the use of full protocols for
a single disorder (Daleiden, Chorpita, Donkervoet, Arensdorf, & Brogan,
Building a Science of Personalized Interventions for PTSD 455

2006) or to the sequencing of full protocols for different disorders (Weisz

et al., 2012). There are no published data regarding patient preferences or
administrator preferences between protocol-­driven versus modular selection
in PTSD. However, treatment duration for modular as compared to stan-
dard protocols tends to be shorter, suggesting greater benefit for the patient
with regard to time commitment and potentially for the health care system
in terms of staff resources and clinician time (Weisz et al., 2012). Lastly, clini-
cians report more positive attitudes about adopting modular therapies com-
pared to standard protocol therapies (Borntrager, Chorpita, Higa-­McMillan,
& Weisz, 2009; Chorpita et al., 2015), suggesting the potential for greater
ease of adoption and dissemination and uptake of these evidence-­based
interventions. Demonstration of the feasibility, effectiveness, and satisfac-
tion associated with the flexible modular approach suggests its potential for
PTSD patients and value in future research.

Sequential Multiple Assignment Randomized

Trial Designs

Research to date on modular therapies has been structured so that the for-
mulation of the treatment to be implemented is generally made at the initial
assessment following a flowchart, with the selection of the modules and their
sequence having been predetermined. The assessment of interest occurs at
the end of the trial (posttreatment and at follow-­up) to determine if the
modular treatment outcome is superior to a standard treatment. An alterna-
tive approach is a sequential multiple assignment randomized trial (SMART;
Collins, Murphy, & Strecher, 2007; Lei, Nahum-Shani, Lynch, Oslin, & Mur-
phy, 2012; Murphy, 2005). In SMART designs, assessments critical to the
process and outcome of a study are conducted at several points across the
treatment, there are repeated randomizations into alternative interventions
based on the periodic assessment results, and the comparator treatment is
not an established standard but another multiple randomization sequence.
SMART designs are useful when no established standard treatment exists
and empirical and/or theoretical guides are not available to create hypoth-
eses about a preferred treatment approach. SMART designs are not tests
of adapted treatments but are used to inform the development of adaptive
treatments, which then can be compared to standard treatments.
To provide a relevant example from the PTSD literature, it is known
that Web-based PTSD programs have better outcomes when there is some
level of therapist involvement, but studies had varied widely regarding the
number of sessions and amount of time that therapists have engaged with
patients (Olthuis et al., 2016). To gather information about the relative ben-
efits of differing amounts of therapist support, a SMART trial could be
designed such that the amount of therapist involvement is adjusted system-
atically from lower to higher amounts contingent on the results of periodic
assessments. This approach would provide answers to many more questions
456 Application, Implementation, and Future Directions

and much more quickly compared to RCTs, which are highly controlled and
do not propose contingency-­based changes for individual participants across
the course of treatment. In SMART designs, there are typically at least two
stages, each with its own randomization procedure, hypotheses, and out-
come evaluation. In this investigation, for example, Stage 1 participants
are randomized into either a no-­therapist Web-based treatment condition
(nWBT) or a biweekly therapist-­supported (bWBT) condition. After 6 weeks,
each participant is classified as a responder or nonresponder (e.g., someone
who has experienced less than a 10-point drop in his or her PTSD score).
Stage 2 is the initiation phase where responders continue in their assigned
condition while the nonresponders in each condition are rerandomized.
In the nWBT condition, nonresponders are randomly assigned to either
biweekly or weekly Web-based treatment (bWBT or wWBT). In the original
bWBT, nonreponders are assigned to weekly WBT or weekly WBT with an
additional phone call as needed (wWBT or w + WBT). The trial is completed
at the end of a second 6 weeks.
This design allows comparison of the two first-stage treatments, nWBT
and bWBT, with regard to their nonresponse rates at the 6th week as well
as the differential benefit observed among the responders at both the 6th
and 12th weeks. It also tests four adaptive interventions in the second stage
(or randomization) of the trial. Determination of the relative benefits of one
adaptation over another can be assessed by comparing outcomes of the pair
of adaptations to which nonresponders have been randomized (bWBT vs.
wWBT, wWBT vs. w + WBT) and as relative to the initial responders.
This type of design can be applied to explore several other types of
treatment questions. For example, the first phase of a SMART RCT might
compare a trauma-­ focused (TF) versus non-­ trauma-­
focused (NTF) treat-
ment. At the end of this phase, nonresponders in each condition would be
randomized again, where, for example, nonresponders to TF receive either
more TF or switch to an NTF, while nonresponders to NTF might either
obtain more NTF or switch to TF. Similarly, two different medications might
be tested in the first randomization phase, and in the second phase, non-
responders could be randomized to an increased dose of the same medica-
tion or a switch to another drug. In both of these examples, the relative
efficacy of two treatments is being assessed in the first randomization, the
relative proportion of nonresponders is being identified, and preliminary
data regarding options for nonresponders are being obtained.

Treatment Selection

One of the most common approaches to personalized mental health is treat-

ment selection, defined as using patient factors to identify the optimal inter-
vention for an individual among a set of available treatments (see Cohen &
DeRubeis, 2018, for an extensive review).
Building a Science of Personalized Interventions for PTSD 457

Historically, treatment selection in mental health and in medicine more

broadly has been practiced through the use of diagnoses. Patients are given
a diagnosis to identify an appropriate and effective treatment. The strategy
of identifying which treatments are helpful for specific disorders has been
formalized in several ways, including efforts to define empirically supported
treatments (ESTs) (Chambless & Hollon, 1998). However, for most mental
health disorders, multiple evidence-­based treatments exist, and there are
relatively few contexts in which a single specific treatment has been identi-
fied as superior to all others and other factors have been investigated.
Patient preference is one. This is appropriate, not only because it
respects the patient’s autonomy and dignity, but also due to the assumed
relationship between a patient’s preference and his or her willingness to ini-
tiate and engage with (or adhere to) a preferred treatment relative to a non-
preferred treatment. To date, the relationship between patient preference
and actual treatment outcomes is unclear, and it likely varies as a function
of myriad contextual factors (e.g., patient’s understanding of or exposure to
the options; the necessity of the patient’s active participation and commit-
ment). In the clinical trials that have examined this association, researchers
have reported results that are positive, negative, and equivocal (Cohen &
DeRubeis, 2018). Regardless, practice guidelines are clear that respecting
patient preference is an essential part of ethical clinical practice.
Clinician judgment also plays a significant role in treatment selection
(Cohen & DeRubeis, 2018). Clinicians who attend to information about a
specific patient’s presentation can generate hypotheses about the patient’s
expected response to a given treatment (Lorenzo-­Luaces, DeRubeis, & Ben-
nett, 2015). For example, Raza and Holohan (2015) surveyed Veterans Affairs
clinicians in the United States who had been trained in both CPT and pro-
longed exposure (PE) with regard to patient variables that they believed
might inform the decision between CPT, PE, or alternative treatments. CPT
was selected over PE for patients with strong guilt, strong shame, acts of
perpetration, and dissociation history, whereas PE was preferred to CPT for
patients with low literacy, low cognitive functioning, and moderate/severe
traumatic brain injury. However, it should be noted that there is not an evi-
dence base to support these selection criteria to date, and it is uncertain
whether these are factors to which clinicians and patients should attend.
Additionally, the complexity of the decision-­making process in the context
of numerous distinct factors suggests that there are opportunities for data-­
driven, multivariable prediction models to help inform the treatment selec-
tion process.

Individualized Metrics

Early research efforts to discover what works for whom largely revolved
around subgroup analyses, in which differences between distinct subgroups
458 Application, Implementation, and Future Directions

(e.g., men vs. women, older vs. younger individuals, presence or absence of
a history of childhood abuse) were examined. When these differences were
detected and determined to be statistically significant, researchers would
claim they had identified a potential moderator, meaning that a variable
had been identified that was associated with differential response across dif-
ferent treatments. These factors have been labeled “prescriptive” variables.
Statistically, this relationship was often detected1 when predicting treatment
response in the form of an interaction between a predictor variable and the
treatment term (sometimes described as an “aptitude-­by-­treatment” inter-
action). These interactions could be “ordinal,” which in subgroup analyses
implies that the difference between expected treatment response exists in
one subgroup but not the other (e.g., Treatment A is better than Treatment
B for men, but no difference is expected between the two treatments for
women). They could also be “disordinal,” involving a full crossover effect
(e.g., Treatment A is better than Treatment B for older individuals, and Treat-
ment B is better than Treatment A for younger individuals). For example,
Rizvi, Vogt, and Resick (2009) identified age as a disordinal prescriptive fac-
tor in an RCT comparing PE to CPT: older women had better outcomes in PE
versus CPT and younger women had better outcomes in CPT relative to PE.
The more common and easily detected effects are prognostic. Prognos-
tic variables are those for which associations with outcome exist either irre-
spective of treatment or for which the relationship is only known for a single
treatment.2 A prognostic relationship can be identified if a variable has been
shown to predict treatment response in the same way across multiple treat-
ments; for example, in an RCT comparing PE and CPT, Rizvi and colleagues
(2009) found that, regardless of the treatment to which the women were ran-
domized, those with higher pretreatment depression and guilt experienced
larger improvements in PTSD symptoms than those with lower depression
and guilt. Alternatively, when a predictive relationship is identified through
the investigation of data from a sample of individuals in which everyone was
provided with the same treatment, that relationship is also said to be prog-
nostic. Importantly, prognostic relationships of this final type should not be
assumed to provide information about what treatment an individual ought to

1 It
is important to note that prescriptive interaction effects can only be truly detected
when data from two or more treatments are examined (Cohen & DeRubeis, 2018).
2 Itshould be noted that although variables are often described as “being” prescriptive
or prognostic, a given factor can have a prognostic relationship with outcome in one
context and a prescriptive relationship in another. For example, if a study comparing
Treatment A versus Treatment B found that individuals’ levels on factor X had the same
association with posttreatment outcome across both treatments, it would be accurate to
describe factor X as prognostic in that study. However, an analysis of a separate study
comparing Treatment A versus Treatment C might find that factor X predicted a dif-
ferential response between those two treatments, and those authors would be justified
in concluding that factor X was a prescriptive variable in their data. Both sets of authors
would be correct.
Building a Science of Personalized Interventions for PTSD 459

receive. It is tempting to infer that a patient with a poor prognosis in a given

treatment should be directed to seek an alternative. However, a patient who
has a poor predicted outcome for a given treatment based on a prognostic
model might be expected to have an equally poor or even worse response to
an alternative treatment.
Despite the multitude of studies examining patient-­specific characteris-
tics of treatment outcomes in depression, anxiety, and to some extent PTSD,
the uptake by clinicians has been minimal at best, due in part to the paucity
of successful replications of the findings. For example, individual variables
such as childhood abuse, depression, dissociation, and severity of symptoms
that have been found to predict outcomes in some studies have been tested
and not found predictive in others (see Cloitre, Petkova, Su, & Weiss, 2016,
for a review). These conflicting results likely have many sources, including
small sample sizes, inconsistent statistical methodology, treatment and sam-
ple heterogeniety, and weak effects of individual predictor variables (Cohen
& DeRubeis, 2018).

Multivariable Prediction Models

Over the last decade, several different solutions for data-­driven, evidence-­
based treatment selection have been described, including Kraemer’s (2013)
“M*” approach; Petkova, Tarpey, Su, and Ogden’s (2016) composite modera-
tor approach; and DeRubeis and colleagues’ (2014) Personalized Advantage
Index (PAI) approach. What these approaches have in common is their appli-
cation of statistical modeling in longitudinal treatment datasets (that com-
prise pretreatment or baseline variables and posttreatment outcome data)
to capture simultaneously the predictive signal from multiple prescriptive
variables. By aggregating the effects of many small but reliable moderators,
these approaches generate recommendations that could lead to clinically
significant differences in patient outcomes.
The composite moderator approach has been used to assess treatment
outcome in PTSD. Through this data-­driven approach, Cloitre and colleagues
(2016) identified patient characteristics that predicted differential outcome
in three multimodular treatment conditions depending on the interventions
included in the sequence. The three conditions included STAIR narrative
therapy, a two-­module treatment in which a skills module was followed by a
trauma-­focused module (the test condition) and two comparator treatments
in which the content of each module was replaced by a nonspecific active
comparator, present-­centered therapy (PCT; called “supportive counseling”
in the study). The two comparators resulted in a delivery of a predominantly
trauma-­focused therapy (PCT plus narrative therapy) and a predominantly
skills-­focused therapy (STAIR plus PCT). The moderator that most strongly
differentiated outcomes was a ratio of patient burden (PTSD, depression, dis-
sociation, interpersonal problems, and anger) relative to a patient strength
460 Application, Implementation, and Future Directions

(emotion regulation capacity). The participants in the STAIR narrative ther-

apy condition showed the best outcomes regardless of ratio. However, par-
ticipants with a low ratio of symptom severity relative to emotion regulation
had better outcomes in the trauma-­focused therapy than in the skills-­focused
treatment, whereas those with a high ratio of symptom severity relative to
emotion regulation had better outcomes in the skills-­focused treatment. If
replicated, these results could be used to match patients with treatments
whereby some patients would receive a trauma-­focused treatment and others
a skills-­based or non-­trauma-­focused treatment based on a ratio identifying
their symptom burden relative to strengths. This variable (a ratio of symp-
tom burden to patient strengths) is an example of a prescriptive variable.
Another treatment selection approach that has been applied to PTSD
is DeRubeis and colleagues’ (2014) PAI approach. Using data from a study
comparing CPT to PE in women with rape trauma PTSD, Keefe and col-
leagues (2018) identified four moderators that predicted differential risk of
dropout between the two treatments: childhood physical abuse, current rela-
tionship conflict, anger, and race. All individuals in the study were random-
ized to either CPT or PE, which did not differ in their dropout rates. After
creating a logistic regression model that tracked the interactions between all
four variables and treatment, the risk of dropout for each individual in both
conditions could be predicted, and the treatment associated with the highest
likelihood of treatment completion identified. Patients who received their
PAI-­indicated treatment had a significantly lower dropout rate (19.7%) com-
pared to those who received their nonindicated treatment (40.5%). If repli-
cated, these findings combined with models designed to maximize symptom
reduction could be used to minimize treatment dropout by helping match
patients to the treatment most likely to result in treatment completion.
Prognostic models have also demonstrated potential utility for treat-
ment selection when deciding between treatments that are not equivalent in
their average treatment effect. Following the approach described by Lorenzo-­
Luaces, DeRubeis, van Straten, and Tiemens (2017), Wiltsey Stirman and col-
leagues (2020) constructed a single prognostic model for a combined sample
of individuals with PTSD treated with either PE or PCT. They found that the
patients with good prognoses who were randomized to receive PE experi-
enced significantly more improvement than patients with good prognoses
who received PCT, whereas patients with poor prognoses showed little to
no advantage when receiving PE versus PCT. The patients predicted to have
poor prognoses were those with higher symptom severity or case complex-
ity, including worse mental and physical functioning, the presence of mili-
tary sexual trauma, longer time since the trauma, and lower endorsement of
treatment credibility. If replicated, these and other models could be used to
inform the collaborative decision-­making processing by which clinicians and
patients determine the best path toward recovery from PTSD.
Nevertheless, one important criticism of these efforts is that the sample
sizes available in the RCT datasets that have been used have been insufficient
Building a Science of Personalized Interventions for PTSD 461

for the purpose of modeling interaction effects (Luedtke, Sadikova, & Kessler,
2019). This has led to recent proposals of alternative modeling approaches
for informing treatment selection, including the use of prognostic models.
One solution proposed by Kessler, Bossarte, Luedtke, Zaslavsky, and
Zubizarreta (2019) allows for researchers to move iteratively between more
exploratory analyses using larger, inexpensive archival datasets and more
controlled tests of precision medicine models in smaller clinical trial data­
sets that can accommodate more extensive measurement. A second solution
(Kessler et al., 2017) is to construct independent prognostic models within
each condition, and to then infer treatment recommendations by compar-
ing the predictions for each treatment generated by the separate models.
Deisenhofer and colleagues (2018) demonstrated this approach in a sample
of individuals receiving TF-CBT or EMDR therapy for PTSD. Age, employ-
ment status, gender, and functional impairment were identified as predict-
ing treatment response among the people receiving TF-CBT, and those four
variables were used to construct a prognostic model for TF-CBT. A separate
prognostic model that relied on only baseline depression and antidepressant
prescription was constructed using data from the subset of the sample who
received EMDR therapy. A new individual’s values on the relevant factors
would be fed into each prognostic model, thus generating separate predic-
tions of treatment response from the two prognostic models (TF-CBT or
EMDR therapy), and the recommended treatment would be identified by
whichever treatment was predicted to lead to a better outcome.

Neurobiological Findings

Since the Institute of Medicine (2011) call for precision medicine specified
for the development of personalized treatment strategies for mental disor-
ders, research methodologies have been suggested to promote such develop-
ment (Leon, 2011; Soliman, Aboharb, Zeltner, & Studer, 2017), with genetics
(Smoller, 2014; Sullivan et al., 2018) and neuroimaging (Etkin, 2014) at the
forefront. Genetic and epigenetic factors, and neuroimaging as well as neu-
roimmunological findings have made substantial contributions to the devel-
opment of therapeutic algorithms that identify treatments likely to provide
good outcome depending on patient characteristics. This approach has been
applied successfully in various medical disciplines for a number of years, for
example, in areas such as oncology (Bristow et al., 2018; Janiaud, Serghiou,
& Ioannidis, 2019), guiding the therapeutic decision making of surgeons,
medical oncologists, and radio-­oncologists.
In mental health, personalized medicine appears to be in its infancy
(Cohen & DeRubeis 2018; Ng & Weisz, 2016). The search for endopheno-
types for major depression has long been suggested (Hasler, Drevets, Manji,
& Charney, 2004). However, as Hellhammer, Meinlschmidt, and Pruess-
ner (2018) pointed out in a recent review, “Psychobiological research has
462 Application, Implementation, and Future Directions

generated a tremendous amount of findings on the psychological, neuroen-

docrine, molecular and environmental processes that are directly relevant
for mental and physical health, but have overwhelmed our capacity to mean-
ingfully absorb, integrate, and utilize this knowledge base” (p. 147).
In mood disorders, some progress has been made with regard to psy-
chosocial risk factors as well as genetic and epigenetic factors, and neuroim-
aging findings (Prendes-­A lvarez & Nemeroff, 2018). For instance, increased
gray matter density in the right inferior frontal gyrus (rIFG) was identified as
a potential biomarker of bipolar disorder (Alda & Manchia, 2018). Further-
more, greater pretreatment ventral and pregenual anterior cingulate cortex
(ACC) activation may predict better antidepressant medication outcome but
poorer psychotherapy outcome (Ball, Stein, & Paulus, 2014). In the field of
anxiety disorders, only a few biological moderators of treatment outcome
across disorders were identified (Schneider, Arch, & Wolitzky-­Taylor, 2015).
Again, genetics and neuroimaging seem to emerge as the most promising
areas of research (Casey & Lee, 2015). As in depression, the ACC appears to
play an important role (Ball et al., 2014).
In the area of trauma-­related disorders, specifically PTSD, the literature
to date on biological moderators of treatment outcome is even more scarce,
and the majority of studies appear to suffer from methodological limita-
tions (Schneider et al., 2015). Smoller (2016) emphasized the role of gene–­
environment interactions and the fact that stress-­related disorders are poly-
genic. Moreover, there appears to be genetic overlap among stress-­related
disorders including PTSD, major depressive disorder, and anxiety disorders.
Large-scale genome-­w ide association studies, epigenome-­w ide associa-
tion studies, and other genomic analyses have demonstrated that the devel-
opment of PTSD is strongly influenced by genetic and epigenetic factors.
The Psychiatric Genomics Consortium PTSD Workgroup led by Karestan
Koenen (Nievergelt et al., 2018) took a systematic approach to developing new
knowledge about the genetic underpinnings of PTSD, using large datasets,
up-to-date technologies, and novel analytic methodologies. For example, the
consortium found that childhood trauma exposure and lifetime PTSD sever-
ity are associated with accelerated DNA methylation age (Wolf et al., 2018).
However, studies looking into genetic or epigenetic predictors of treatment
outcome are still scarce. In a small pilot study of PE therapy with combat
veterans suffering from PTSD, methylation of the GR gene (NR3C1) exon 1F
promoter assessed at pretreatment predicted treatment outcome (Yehuda et
al., 2013). More recently, Pape and colleagues (2018) identified pretreatment
NR3C1 methylation levels as a potential marker to predict PTSD treatment
outcome, independent of the type of therapy.
With regard to neuroimaging markers, the subgenual anterior cingulate
cortex (sgACC), default mode network, and salience network seem to play an
important role as outcome predictors of transcranial magnetic stimulation
for PTSD (Philip et al., 2018).
Building a Science of Personalized Interventions for PTSD 463

Shvil, Rusch, Sullivan, and Neria (2013) reviewed neural, psychophys-

iological, and behavioral markers of fear processing in PTSD. It remains
to be studied, however, to what degree markers of fear processing, such as
hyperactivation of the amygdala, dorsal ACC, and insula, and hypoactiva-
tion in other brain areas, turn out to be sufficiently robust treatment out-
come markers as well. The same applies to psychophysiological variables
such as startle response, heart rate variability, or skin conductance response.
In a recent small psychotherapy outcome study of a combination of CBT
for substance use disorder with CPT for PTSD, Soder and colleagues (2019)
identified baseline resting heart rate variability as a possible biomarker pre-
dicting PTSD treatment outcomes in adults with co-­occurring substance use
disorder and PTSD. The authors concluded that patients with poorer auto-
nomic emotional regulation, as reflected by low heart rate variability, may
not respond as well to psychotherapy in general.
Taken together, there is an emerging body of literature on putative bio-
markers that might be used as predictors of PTSD treatment outcome. It
can be expected that in the future, such biomarkers will be used to develop
personalized treatment strategies for people with PTSD, and to inform col-
laborative processes of joint decision making among therapists and their
patients. At this point in time, however, the development of therapeutic algo-
rithms to optimize clinical outcomes of empirically supported therapies has
a limited evidence base.

Conclusions

The goal of personalized therapy research is to generate a body of knowl-

edge that will translate to clinical services such that therapists will be able to
provide the most effective treatment in the most efficient manner to every
patient based on their individual symptoms, characteristics, and preferences.
This chapter has identified some of the conceptual and methodological
building blocks that are contributing to the development of a science of per-
sonalized intervention. These include study designs that involve the system-
atic adaptation of treatments for specific populations, evaluation of flexible
sequencing of modular interventions, and SMART designs that allow for the
rapid testing and identification of adaptations likely to succeed. The build-
ing blocks also include statistical strategies and computer power that can
analyze vast amounts of data to provide reliable information about which
psychological, social, or genetic and other neurobiological characteristics
are associated with what types of outcomes in which treatments, facilitating
a match of patient to treatment to optimize outcome. Hopefully, these build-
ing blocks of treatment designs and statistical analyses can be productively
stacked together to advance science and provide answers to the question
that has long been asked: What works for whom? If successful, personalized
464 Application, Implementation, and Future Directions

intervention science will provide a research and treatment pathway that will
markedly alter the nature of mental health care services.

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C H A P TE R 2 4

Training and Implementation

of Evidence‑Based Psychotherapies
for PTSD
David S. Riggs, Maegan M. Paxton Willing, Sybil Mallonee,
Craig Rosen, Shannon Wiltsey Stirman, and Shannon Dorsey

D espite strong empirical evidence for the effectiveness of evidence-­based

psychotherapies (EBPs) for posttraumatic stress disorder (PTSD; Ameri-
can Psychological Association, 2017; International Society for Traumatic
Stress Studies [ISTSS], 2018), they are not commonly available in clinical care
settings (e.g., Chorpita et al., 2015; Weisz, Doss, & Hawley, 2005). To better
understand the low rates of EBP utilization, it is important to examine cur-
rent training and implementation efforts. A number of training programs
have been developed to instruct clinicians, often across widely dispersed
health care systems, in the use of these treatments with the goal of increas-
ing their utilization (Chorpita et al., 2015; Karlin et al., 2010; McHugh &
Barlow, 2010). In high-­income countries, large-scale efforts have been made
to implement EBPs, including the large-scale implementation efforts by the
U.S. Department of Veterans Affairs (VA) (Eftekhari et al., 2013; Karlin et
al., 2010), Department of Defense (DoD) (Borah et al., 2013; Wilk et al.,
2013), and international efforts such as the Improving Access to Psychologi-
cal Therapies (IAPT) Program in England (Clark, 2018). In addition, man-
dates, incentives, and promotional efforts have been put in place to facili-
tate implementation of EBPs (McHugh & Barlow, 2010). Although several
programs have proven successful at training large numbers of clinicians,
even when providers are adequately trained to use a treatment, successful
implementation of EBPs in client-­serving settings has been much slower
than expected (e.g., Chorpita et al., 2015; Weisz et al., 2005). A growing

469
470 Application, Implementation, and Future Directions

body of research from the field of implementation science demonstrates that

dissemination and training alone do not ensure that EBPs will be adopted
and effectively delivered. In this chapter, we review efforts and challenges
in the implementation of EBPs for PTSD and provide some suggestions for
overcoming the apparent barriers to their use.

Teaching Providers Treatments That Work

Training is a necessary but not sufficient strategy for EBP implementation.

Historically, EBP training focused on training clinicians with advanced
degrees (i.e., doctoral or master’s level) and occurred within extended train-
ing programs (i.e., graduate training, postdoctoral fellowships). Initially,
efforts to disseminate EBPs to practicing clinicians largely relied on provid-
ers’ self-study of published treatment manuals to learn protocols and tech-
niques (Mallonee, Phillips, Holloway, & Riggs, 2018). However, with growing
research and experience, it became clear that this method of dissemination
was not effective (e.g., Fixsen, Naoom, Blase, Friedman, & Wallace, 2005).
In response, dissemination efforts that combine treatment manuals with in-­
person training by experts have become the most widely used method of
dissemination (Dimeff et al., 2009).
A recent review by RAND (Hepner, Holliday, Sousa, & Tanielian, 2018)
of 57 studies on training identified the key components of effective EBP
training programs associated with greater treatment fidelity. In conjunction
with its report, RAND developed a Training in Psychotherapy (TIP) tool
(Hepner et al., 2018) that may be useful in evaluating various training pro-
grams. According to the RAND report, effective training typically includes a
didactic element to teach and demonstrate the skills as well as a consultation
or supervision period. Certification is available for some EBP training pro-
grams; however, there is a dearth of evidence regarding its role in strengthen-
ing fidelity (Hepner et al., 2018). Currently, no broadly accepted certification
guidelines or requirements exist, and certification is commonly left to the
determination of the trainer or treatment developer. Certification may be a
useful tool to encourage trainees to reach utilization benchmarks outlined in
the certification requirements, but that has not been established empirically.

Didactic Training Components

In-­person workshops are generally effective at increasing trainee knowl-
edge about and attitudes toward an EBP, but do not always result in trainee
behavioral change (Beidas & Kendall, 2010; Herschell, Kolko, Baumann, &
Davis, 2010). However, didactic trainings vary widely in format (e.g., work-
shop training or manual-­based learning) and time (e.g., self-paced, massed
over a multiday period, or spaced out over time). The training associated
with increased EBP fidelity typically consisted of workshops lasting at least
Training and Implementation of Evidence‑Based Psychotherapies 471

2 days and integrated written materials (e.g., training manuals, handouts)

with didactic presentations (Hepner et al., 2018). Training that included
skills demonstration and/or interactive components like role plays or behav-
ioral rehearsal (see Beidas, Cross, & Dorsey, 2014, for guidance on use) were
associated with greater adherence to, and competence in, the EBP. However,
the specific methods of demonstrating skills or promoting learner interac-
tion varied widely (Hepner et al., 2018). Feedback offered to learners (com-
ments on role plays or responses to homework assignments) during training
appears useful to clarify and correct trainee perceptions while increasing
their skills and understanding. Because feedback commonly occurs in con-
junction with interactive trainings, it is unclear which contributes more to
fidelity (Hepner et al., 2018). In terms of content, training programs typi-
cally present information on the theory underlying the EBP, empirical sup-
port for its use, key components of the treatment, and clinical decision mak-
ing in applying the EBP (Hepner et al., 2018). The depth and modality with
which each of these elements is covered vary widely across programs. To
date, there are no studies that explore the relative value of these elements or
various teaching methods in the dissemination of EBPs.

Remote Delivery of Didactic Training

In-­person workshops represent the most common form of EBP training for
professionals, but they are not without challenges. Providers may be unable
to travel to workshops due to financial or logistical restrictions (see Mal-
lonee et al., 2018). In addition, the limited availability of qualified trainers
combined with a limited capacity in the workshop constrains the ability to
widely disseminate EBPs.
To address some of these barriers, online training has become an alter-
native method of disseminating EBPs for PTSD. There are multiple online
platforms and approaches differing with regard to factors such as learner
control and involvement that may impact training effectiveness (Dalgarno
& Lee, 2010; Harned, Korslund, & Linehan, 2014; Weingardt, 2004). Asyn-
chronous online training (e.g., CPTweb, PEWeb, TF-­CBTweb) is self-paced
and designed to be completed at a time convenient for the learner. Studies
have found asynchronous training produces knowledge gains equivalent to
in-­person training, although often gains in knowledge, EBP adherence, and
EBP skill for any training conditions are modest (Beidas, Edmunds, Mar-
cus, & Kendall, 2012). Dimeff and colleagues (2015) determined that online
training produced greater knowledge gains than an in-­person workshop,
but the workshop produced greater increases in self-­efficacy and motiva-
tion than did online training. Although asynchronous training is available
at clinicians’ convenience, the lack of a defined schedule may make it more
difficult for some clinicians to dedicate time for training.
Alternatively, synchronous online platforms offer the opportunity for
instructor-­led, live workshops (Mallonee et al., 2018). We are aware of two
472 Application, Implementation, and Future Directions

such platforms that have been used in disseminating PTSD treatments to

date: (1) video conferencing (Rakovshik, McManus, Vazquez-­Montes, Muse,
& Ougrin, 2016) and (2) SecondLife, a three-­ dimensional avatar-­ based
e-­learning platform (Mallonee et al., 2018; Paxton Willing et al., 2018; Ruzek
et al., 2014). The existing research of online training, though limited, sug-
gests that it is at least equally as effective as in-­person training (Dimeff et
al., 2015; German et al., 2017; Mallonee et al., 2018; Stein et al., 2015), is less
expensive, and can reach multiple providers at a distance (Harned et al.,
2014; Weingardt, 2004). One recent study focused on teaching prolonged
exposure (PE) and cognitive processing therapy (CPT) found that Second­
Life learners had similar gains in knowledge and a similar or greater sense
of readiness than did learners attending in-­person workshops; indeed, the
SecondLife CPT learners reported larger increases in readiness than did the
in-­person CPT learners (Paxton et al., 2018). However, learners were signifi-
cantly more satisfied with the teaching methods used in the in-­person work-
shop than those used in SecondLife, perhaps due to their greater familiar-
ity (Paxton Willing et al., 2018). Notably, positive outcomes like knowledge,
attitudes, or readiness do not ensure provider behavioral change (e.g., EBP
adoption, EBP delivery with fidelity).

Consultation
Although in-­person workshops or virtual training appear effective at impart-
ing knowledge, it has been demonstrated that some form of applied learn-
ing in which the provider is evaluated and given advice from a qualified
clinician while using the EBP is an essential aspect of developing skills and
competence (Hepner et al., 2018; Herschell et al., 2010; Nadeem, Gleacher, &
Beidas, 2013). Such training, typically considered clinical supervision, is an
integral part of professional training programs (Nadeem et al., 2013). When
disseminating EBPs through workforce education, the applied portion of
the training is commonly referred to as consultation. Consultation provided
following initial workshop training has been shown to improve provider atti-
tudes toward the EBP (Barnett et al., 2017; Ruzek et al., 2016), to strengthen
adherence and competence (Hepner et al., 2018; Rakovshik et al., 2016), to
improve patient outcomes (Monson et al., 2018), and to increase learners’
subsequent use of the EBP in practice (Charney et al., 2019). Nonetheless,
there may be significant challenges in getting providers to dedicate the nec-
essary time for posttraining consultation (Smith, 2017). For reviews of con-
sultation and its relationship to implementation, see Edmunds, Beidas, and
Kendall (2013) and McLeod and colleagues (2018).
Although it is generally agreed that some form of consultation follow-
ing workshop training is valuable, there is a scarcity of empirical data on
the optimal format or amount of consultation (Hepner et al., 2018). Feed-
back may be offered in person, via telephone, or via video-­teleconference.
Consultation is sometimes offered one-to-one but more often provided in a
Training and Implementation of Evidence‑Based Psychotherapies 473

group with one expert and several learners. In one nonrandomized study,
Stirman and colleagues (2017) found that providers who received group
consultation with audio review showed increased competence with the EBP,
whereas those receiving individual supervision and audio review decreased
in competence 2 years after consultation ended. Some EBPs for PTSD (e.g.,
trauma-­focused cognitive-­behavioral therapy [TF-CBT]; Cohen, Mannarino,
& Deblinger, 2006) require a period of consultation following the initial
training as part of the certification. One study examining implementation
of multiple EBPs, some of which required consultation following training
and some of which did not, found that clinicians appreciated the posttrain-
ing consultation (Barnett et al., 2017).
Consultation typically, but not always, incorporates material from learn-
ers’ own cases (Hepner et al., 2018). At the most resource-­intensive level,
this involves having the consultant listen to audio or view video recordings
of EBP sessions to provide feedback to the learner on the content and qual-
ity of the EBP delivery (e.g., Eftekhari et al., 2013; Stirman et al., 2017).
Recognizing the cost of this approach, other consultation programs review
case materials (Chard, Ricksecker, Healy, Karlin, & Resick, 2012), discuss
case conceptualization (Waltman, Hall, McFarr, & Creed, 2018), or review
a limited number of recorded sessions (Charney et al., 2019) or segments
of recorded sessions (Monson et al., 2018; Stirman et al., 2017). There are
few data that address questions of whether and how much material needs
to be reviewed for consultation to be effective. In a randomized trial, Mon-
son and colleagues (2018) found that CPT workshop training plus standard
consultation (without audio review) produced better patient outcomes than
workshop training only. Yet contrary to predictions, CPT consultation with
audio review of session content produced poorer patient outcomes than did
standard CPT consultation.
In our experience, the provision of consultation is one of the primary
rate-­limiting factors for efforts to disseminate and promote the implementa-
tion of EBPs for PTSD. The expenses associated with providing consultation
are high in terms of expert and learner time as well as the logistical require-
ments. Broad, effective implementation of EBPs will likely require new, less
resource-­intensive models for providing consultation that still promote com-
petency and confidence in the delivery of the protocols (e.g., German et
al., 2017). Developing more efficient training models is especially important
because frequent staff turnover (Mor Barak, Nissley, & Levin, 2001) and role
changes often necessitate repeated training events to maintain a trained
staff (Beidas, Marcus, et al., 2016; German et al., 2017).

Training Staff in Low‑Resource Countries

Most programs aimed at training individuals to deliver EBPs for PTSD have
focused on training mental health professionals. However, in low-­resource
countries with few mental health professionals, it is possible to train lay
474 Application, Implementation, and Future Directions

counselors or paraprofessionals to deliver EBPs. Studies in low-­resource

countries have shown that lay personnel can be trained to effectively deliver
narrative exposure therapy (Neuner et al., 2008), CPT (Bass et al., 2013;
Bolton, Bass, et al., 2014), trauma-­focused CBT (Murray et al., 2015), and the
Common Elements Treatment Approach (CETA; Bolton, Lee, et al., 2014;
Weiss et al., 2015). Such efforts require adapting treatments for local culture
and literacy levels, more extended training, building a local cadre of supervi-
sors for the EBP, and connections to mental health professionals for address-
ing safety concerns and other mental health issues (e.g., psychosis; Murray et
al., 2011; Patel, Chowdhary, Rahman, & Verdeli, 2011). Low-­resource coun-
tries often face additional implementation challenges that we cannot fully
address here. These may include limited funding for social services, lack of
mental health infrastructure, and sociopolitical instability (Chen, Olin, Stir-
man, & Kaysen, 2017).

Examples of Large‑Scale Training Efforts

In high-­income countries, large-scale efforts to implement EBPs for PTSD
have been under way over the last decade. In the United States, the VA’s
dissemination efforts began in 2006 by conducting regular national in-­
person workshops and weekly phone call consultation posttraining (Karlin
et al., 2010). These efforts continue, although they now have transitioned
to a decentralized model, with workshops and consultations conducted
at regional levels. The Department of Defense (DoD) also began training
efforts in 2006 using somewhat different processes than the VA. The most
notable difference is that DoD did not mandate consultation following work-
shop training, choosing instead to offer voluntary telephonic consultation.
These efforts resulted in a large number of providers trained in PE and/or
CPT, but barriers to delivering these treatments remain (Borah et al., 2013;
Finley et al., 2015; Wilk et al., 2013), despite additional policy activities to
support implementation (Karlin & Cross, 2014).
Efforts within civilian communities to increase implementation have
typically been slower and more heterogeneous in nature. Often these efforts
are driven by treatment developers or groups of early adopters who conduct
workshops and provide consultation as an extension of the development of
the treatment. Over time, networks of trainers and communities of trained
providers may emerge. Examples of this can be seen in the dissemination
of eye movement desensitization and reprocessing (EMDR) therapy and
CPT (with its foundation in the VA implementation effort). Other efforts
to disseminate evidence-­based treatments among civilian providers reflect
the work of government agencies. For example, although focused on the
treatment of serious mental illness rather than PTSD specifically, individual
states have implemented policies to increase the delivery of EBPs. Many of
these include the development of state training programs in various EBPs
(Bruns et al., 2016).
Training and Implementation of Evidence‑Based Psychotherapies 475

Over 17 states have developed TF-CBT training initiatives to better

equip child- and adolescent-­serving providers to address trauma-­exposure
sequelae (Sigel, Benton, Lynch, & Kramer, 2013). These initiatives have
received widely varying financial support by states or grants, and all have
included posttraining consultation or clinician coaching. They also have
included a range of implementation supports to supplement in-­person train-
ing, including assessment of organizational readiness to adopt and use qual-
ity assurance procedures to address implementation barriers, engagement
of important stakeholders (e.g., child welfare, court representatives), and
supervisor-­specific trainings and supports (Sigel et al., 2013). The Wash-
ington State Initiative builds on work by Weisz and colleagues (2012) and
extends beyond TF-CBT (Dorsey, Berliner, Lyon, Pullmann, & Murray,
2016) to include CBT for the other most commonly presenting child mental
health problems. With supervisors and organizational leaders in community
mental health, this group has developed three practical guides that orga-
nizations can access on their website, to provide guidance on implement-
ing EBPs (http://depts.washington.edu/hcsats/PDF/TF-%20CBT/pages/thera-
pist_resources.html#; Berliner, Dorsey, Merchant, Jungbluth, & Sedlar, 2013;
Berliner, Dorsey, Sedlar, Jungbluth, & Merchant, 2013).
In addition, the National Child Traumatic Stress Network (NCTSN)
supported the development of an asynchronous online training program,
developed by the Medical University of South Carolina, that has been suc-
cessful at increasing the spread of TF-CBT (Amaya-­Jackson, Ebert, Forrester,
& Deblinger, 2008). It aimed to create assessments and EBPs that were both
developmentally and culturally appropriate that would be disseminated
across diverse clinical settings. The NCTSN works to develop “state-of-the-
art training platforms and to disseminate, implement, and adapt evidence-­
based treatments into community practices across the network” (Amaya-­
Jackson et al., 2008, p. 393). By utilizing a collaborative learning model, the
NCTSN has been able to disseminate and implement EBPs within a number
of diverse sites.
The United States is not the only country with large-scale efforts for
EBP dissemination. For example, England has developed the IAPT Program
whose mission is to minimize the gap between research and practice. This
program was initiated by a coalition of clinical researchers and economists
who emphasized to the public and to policymakers both the economic and
social benefits of such a program (Gyani, Shafran, Layard, & Clark, 2013).
The program includes the recommendation of CBT in the National Institute
for Health and Care Excellence (NICE) treatment guidelines, of transpar-
ency in publishing outcome data on a quarterly basis, and also has included
cost analyses to demonstrate the return on investment in training and dis-
semination. Upon approval, the program established a goal to train over
10,500 new therapists in the use of EBPs for a variety of disorders, including
PTSD, by 2021. Although the program had a slow start when it began in 2008,
it has gradually increased and is on target to meet its 2021 goal (Clark, 2018).
476 Application, Implementation, and Future Directions

Within the IATP, training of providers in EBPs is conducted over the

course of a year, during which they attend lectures on the EBPs at local
universities, workshops, and case supervision 2 days a week. During the rest
of the week, they see patients at local IAPT agencies, while receiving addi-
tional regular supervision and the opportunity to observe more experienced
staff (Clark, 2011). The transparency of this program has allowed detailed
research to be conducted on clinical outcomes both to monitor the effective-
ness of the program as a whole and also to gain additional information to
maximize clinical outcomes. For example, in one study early in the devel-
opment of this program, researchers determined recovery rates of around
40%, improvement rates of approximately 64%, and deterioration rates of
6.6% (Gyani et al., 2013). Of note, despite the fact that the 40% recovery rate
is about 10% less than IATP’s recovery rate goal, the program exceeded its
goal of moving people off of sick pay and/or state benefits due to their men-
tal illness by more than 2,000 individuals (Clark, 2011). However, it was also
found that these rates were impacted by the efficacy of practitioners to the
NICE guidelines, with those following the guidelines more closely having
better outcomes (Gyani et al., 2013).
In addition, the evidence-­based practice task force of the Canadian
Psychological Association (CPA; 2012) recommended a tridirectorate
approach to dissemination to include the Education, Practice, and Sci-
ence directorates. It advised these committees to use annual conventions,
symposia, seminars, and continuing education opportunities to dissemi-
nate EBPs to providers. Together for Mental Health details an approach
to improving the psychological health of the people of Wales as well as
encouraging the use of EBPs (Welsh Government, 2012). In this endeavor,
a number of initiatives to improve mental health have been established
along with efforts by organizations within Wales to offer training for pro-
tocols such as Mental Health First Aid. For example, the All Wales Mental
Health Promotion Network works to assemble and disseminate evidence
in support of mental health improvement. The network recommends that
providers continually monitor their practice, including patient outcomes
and quality of care.

Contextual Factors in Implementation

As noted in earlier sections, dissemination and training are necessary but

insufficient for ensuring that EBPs are actually delivered to individuals with
PTSD (e.g., Herschell et al., 2010; Hershcell, Reed, Person Mecca, & Kolko,
2014; Monson et al., 2018). For example, despite training and policy direc-
tives, within the VA, it is estimated that 80% of patients with PTSD do not
receive an EBP (Maguen et al., 2018). Recent research has shown that even
behavioral health providers trained in the use of EBPs for PTSD are choos-
ing not to use them (Borah et al., 2013), use them for only a small proportion
Training and Implementation of Evidence‑Based Psychotherapies 477

of their patients (Finley et al., 2015; Rosen et al., 2017), or use them with low
fidelity to the EBP protocol (Thompson, Simiola, Schnurr, Stirman, & Cook,
2018; Wilk et al., 2013).
A number of studies have begun to explore factors that limit the imple-
mentation of EBPs for PTSD within health care systems. In the United
States, much of this work has been focused on the VA and DoD health care
systems for adults and in community mental health settings for children and
adolescents. Rosen and colleagues (2016) reviewed 32 papers that examined
aspects of the dissemination and implementation of PE and CPT within the
VA and identified three important determinants of EBP use: clinician con-
fidence in the effectiveness of the treatment, facility/organizational support
for the delivery of the EBP, and overcoming challenges in patient engage-
ment with the treatment (Rosen et al., 2016). Similarly, Borah, Holder, Chen,
and Gray (2017) identified clinician and organizational factors that limit the
use of EBPs among DoD clinicians. Researchers at the Center for Deploy-
ment Psychology (CDP; 2015) have worked to identify barriers to EBP imple-
mentation based on their work to increase EBP use in the DoD health care
system. The result of this effort is a list of more than 35 potential barriers
that includes clinician factors (e.g., confidence in their ability to deliver EBP,
belief in the efficacy of the treatment), patient characteristics (e.g., knowl-
edge about EBP), and clinic factors (e.g., resource requirements) similar to
those found in other studies (Borah et al., 2017; Rosen et al., 2016). However,
a number of the barriers to EBP implementation were broader and more
far-­reaching (e.g., inability to schedule appointments around duty require-
ments). These were termed systemic barriers and are similar to contextual
factors that have been found to impact the delivery of EBPs (Beidas & Kend-
all, 2010; Glisson & Williams, 2015). Yet, existing dissemination/implemen-
tation programs have largely focused on training providers and thus not
adequately addressed other barriers to implementation.

Strategies to Address Barriers to Dissemination

and Implementation
As discussed previously, multiple factors function to limit the implemen-
tation of EBPs for PTSD. These include provider knowledge and beliefs,
patient beliefs about EBPs, and clinic climate, resources, and policies. The
implementation literature has identified a number of strategies to over-
coming barriers. It is beyond the scope of this chapter to identify specific
approaches to overcoming the myriad of organizational barriers to EBP
implementation. However, we will offer several broad approaches that may
prove helpful in promoting EBP use. First, comprehensive approaches to
preparing and supporting organizations and clinicians to implement EBPs
are needed. Although the best approaches are still being identified, multi-
faceted approaches such as learning collaboratives (LoSavio et al., 2019) and
tailored combinations of implementation strategies show promise.
478 Application, Implementation, and Future Directions

Waltz and colleagues (2015) detail a six-point approach that includes

planning, education, financing, restructuring, managing quality, and attend-
ing to policy context. In conjunction with a needs assessment that involves
multiple stakeholder perspectives and, if possible, evaluation data, appro-
priate strategies can be mapped onto identified barriers and facilitators at
the individual (provider, patient), organizational, system/outer context, and
intervention levels (Lewis et al., 2018; Powell et al., 2017). The recommenda-
tions below leverage these categories to provide a framework for a multifac-
eted, flexible approach to overcoming implementation barriers.

System‑ and Policy‑Level Approaches

Efforts to promote implementation are often impacted by large-scale
changes in policy or process (Stirman, Gutner, Langdon, & Graham, 2016).
For example, the VA’s EBP for PTSD implementation efforts involved the
expansion of their mental health care workforce as well as mandates stat-
ing that CPT or PE must be a treatment option at all facilities (Karlin et
al., 2010; Karlin & Cross, 2014). Significant efforts to encourage the use of
EBPs, including changes in policies and fiscal incentives, have been made by
individual U.S. states (Bruns et al., 2016). The treatments studied by Bruns
and colleagues were geared toward care for serious mental illness rather
than PTSD specifically. However, their research raises an important concern
in that their analyses suggest the trend of increased EBP implementation
observed in the early 2000s has flattened or even begun to decline (Bruns
et al., 2016), pointing to challenges in the sustainability of implementation
efforts that have not yet garnered much attention in the literature.
There have been large-scale pushes for implementation EBPs in gen-
eral (Bond & Drake, 2019). For instance, policy changes and mandates have
occurred in many countries, as illustrated by the Mental Health Policy in
England briefing paper that emphasized the need for the utilization of EBPs
(Parkin, 2018). Additionally, the National Health and Medical Research
Council of Australia has stated that treatment guidelines should utilize evi-
dence to form their recommendations (Silagy, Rubin, Henderson-­Smart, &
Gross, 1998). Several psychological societies, such as the Canadian Psycho-
logical Association (2012) and Australian Psychological Society (2018), have
provided treatment guidelines that focus on the need for EBPs. Even grander
efforts are being undertaken to promote the use of EBPs. For example, the
Programme for Improving Mental Health Care (PRIME) was designed to
increase the implementation of EBPs in primary care and maternal health
care centers in countries like India, Nepal, Ethiopia, Uganda, and South
Africa (Lund et al., 2012).
Treatment guidelines and policy statements supporting the application
of EBPs are positive developments, but they merely encourage their use; they
do not mandate, reward, or resource use of these treatments. More powerful
policy changes to support the spread of EBPs would require more serious
Training and Implementation of Evidence‑Based Psychotherapies 479

social commitments. In low-­resource countries, this would require advocacy

to increase funding for mental health services (Chen et al., 2017) or a rede-
sign of EBPs to be more inherently sustainable. In high-­resource countries,
shifts to incentivize the use of EBPs could include professional accreditation
bodies requiring that clinicians have EBP trainings, health care organiza-
tion or funders requiring that providers have the capacity to deliver EBPs,
making the provision of EBPs part of health care quality or performance
measures, billing and reimbursement policies that incentivize the provision
of EBPs, routine measurement and reporting of patient outcomes, and/or
payment policies based in part on patient improvement. To date, there has
been limited research on how such economic incentives impact EBP use
and patient outcomes in mental health (Stewart, Lareef, Hadley, & Mandell,
2017; Yuan, He, Meng, & Jia, 2017).

Local Organizational Context

In addition to being influenced by forces at the societal and policy levels,
the implementation of EBPs is also strongly impacted by factors at the clinic
or practice levels (inner context). EBP clinic-­level organizational factors are
often critical to the successful implementation of EBP protocols (Aarons,
Hurlburt, & Horwitz, 2011; Damschroder et al., 2009; Sayer et al., 2017). In
our experience, if clinic policies focus on efficiency (throughput) rather than
effectiveness (outcomes), provide no ability to compare clinic outcomes, and
do not offer opportunities/support for posttraining consultation, then the
culture of the clinic is not encouraging the use of EBPs (Glisson et al., 2008),
and research further supports this experience (Glisson & Williams, 2015;
Sayer et al., 2017).
Factors at the organizational level also impact clinician attitudes and
willingness to deliver EBPs. A positive organizational climate has been
associated with more positive attitudes toward EBPs (Aarons & Sawitsky,
2006). Other studies have indicated that leadership support and character-
istics are also associated with more positive attitudes (Aarons, 2004; Aar-
ons, Ehrhart, Farahnak, & Hurlburt, 2015; Aarons & Sommerfeld, 2012).
Clinic managers and/or clinical supervisors can promote EBP use by offer-
ing incentives or rewards for indications of EBP adoption, such as meeting
implementation goals, offering peer education or supervision, conducting
chart reviews to assess and support EBP use, or highlighting improvement
in patient outcomes (Aarons, Ehrhart, Farahnak, & Sklar, 2014). In a study
examining workplace-­based supervision of TF-CBT (i.e., supervision deliv-
ered by supervisors already employed in the clinic), supervisors in clinics
that had a more positive implementation climate were more likely to spend a
higher percentage of their supervision time on EBP-­relevant clinical content
(i.e., case conceptualization, interventions; Dorsey et al., 2018). A more posi-
tive implementation climate was also associated with supervisors’ greater
coverage of TF-CBT elements (Lucid et al., 2018; Pullmann et al., 2018).
480 Application, Implementation, and Future Directions

Thus, facilitating a supportive implementation climate and preparing clinic

leaders to facilitate and reinforce EBP use may be at least as important as
directly addressing clinician attitudes through training or motivational
interventions. Clinics can also support EBP implementation by prioritizing
the hiring of applicants with EBP interest and experience, and by providing
support for training inexperienced clinicians. One of the Washington State
organizational practical guides focuses specifically on orienting new provid-
ers to EBP given the ongoing challenge of workforce turnover (Berliner,
Dorsey, Merchant, et al., 2013).
Another important organizational factor is alignment of resources to
support EBP delivery. Studies comparing VA clinics and residential pro-
grams that were more and less successful in implementing EBPs suggest
prioritization is key. Successful programs not only created a culture that
values EBPs, they also aligned staff time and adjusted the workflow to sup-
port their implementation (Cook et al., 2015; Sayer et al., 2017). Clinics may
explore the possibility of restructuring or simplifying administrative tasks to
improve provider productivity or aligning documentation requirements with
EBP reporting standards. Transferring some tasks to administrative staff or
behavioral technicians (Matsuzaka et al., 2017) and reducing or eliminat-
ing ineffective interventions (e.g., open-ended support groups) can increase
providers’ time to learn and deliver EBPs. EBP implementation may benefit
from more substantial changes to policy and processes, such as procedures
for scheduling appointments, patient referral processes, case management
procedures, or other clinic operations (Sayer et al., 2017).

Fidelity Support
Within the dissemination and implementation literature for PTSD treat-
ments, the question of how well providers maintain treatment fidelity and
competence over time has received relatively little attention. Data that sug-
gest providers fail to deliver the treatment with fidelity (e.g., Wilk et al.,
2013) are often interpreted to mean the initial training was inadequate.
However, it is also possible that providers did learn to deliver the EBP in
line with the protocol but subsequently drifted away from the manual (Cen-
ter for Deployment Psychology, 2015). It may be necessary to incorporate
strategies to assess provider fidelity/competence over time and provide addi-
tional guidance (e.g., refresher training, additional consultation) if drift is
detected. There is a need for both effective (e.g., accurate assessment) and
efficient (low-cost, low-­burden) strategies to assess fidelity so that organiza-
tions can better assess when drift is occurring (Beidas, Maclean, et al., 2016;
Schoenwald et al., 2010).
Ensuring that providers have ongoing access to expert consultation (at
least on an ad hoc basis), peer consultation, or workplace-­based supervision
that focuses specifically on the EBP may be particularly useful when they
are faced with complicated cases (Edmunds et al., 2013). Despite evidence
Training and Implementation of Evidence‑Based Psychotherapies 481

that EBPs for PTSD often produce improvements for comorbid problems
as well (see Riggs, Tate, Chrestman, & Foa, Chapter 12, this volume), clini-
cians may assume that the treatment will be ineffective, or even harmful for
clients who have complex needs (Center for Deployment Psychology, 2015).
Clinic case conferences or provider testimonials that share successes and les-
sons learned in implementing EBPs with complex cases can help colleagues
adapt rather than abandon EBPs with such patients (Center for Deployment
Psychology, 2015). To better tailor the techniques used to address concerns
and skepticism, it is also important to understand clinicians’ worldviews and
approach toward practice, to determine whether their concerns about EBPs
are more deeply rooted or motivated (Hornsey & Fielding, 2017).
A potentially important tool for addressing clinicians’ concerns about
the impact of EBP implementation on their clients is the adoption of
measurement-­based care practices (Fortney et al., 2016). Acknowledging
that this often kicks off an entirely new implementation exercise, the inte-
gration and use of outcome measures (e.g., PTSD Checklist [PCL-5]; Blevins,
Weathers, Davis, Witte, & Domino, 2015) in treatment planning and evalua-
tion can help address many provider concerns. For example, it will allow the
evaluation of (1) comparative outcome of clients treated with the EBP and
those receiving other treatment, (2) treatment safety, and (3) the impact of
modifying the EBP protocol (Center for Deployment Psychology, 2015). The
clinicwide use of measurement-­based care can also contribute to improved
treatment response (Fortney et al., 2016).

Patient Engagement
Some providers may be hesitant to utilize EBTs due to beliefs that patients
will not be receptive to the protocol (Center for Deployment Psychology,
2015; Rosen et al., 2017). However, patient receptivity is often a function of
how they are educated about treatments. Providers should be trained on best
practices in describing EBPs and provided with tools to increase patient buy-
in while targeting their safety concerns and misconceptions. Tools for joint
decision making around the treatment of PTSD have been shown to improve
patient engagement and retention in EBPs (Mott, Stanley, Street, Grady, &
Teng, 2014; Watts et al., 2015). Online resources for comparing treatment
approaches (www.ptsd.va.gov/apps/decisionaid) can be used to support a col-
laborative approach to deciding which treatment approach to pursue with a
particular client. Evidence-­based engagement strategies can also be paired
with EBPs, such as those developed by Mary McKay and colleagues, that
help providers address both perception issues (e.g., stigma, negative past
experiences with mental health care) and barriers to engagement (Dorsey
et al., 2014; McKay & Bannon, 2004). In a small randomized controlled trial
focused on engaging youth and foster parents, TF-CBT supplemented with
McKay’s evidence-­based engagement strategies outperformed standard TF-
CBT in preventing early treatment dropout (Dorsey et al., 2014).
482 Application, Implementation, and Future Directions

Conclusions

For implementation efforts to be effective, one must allow sufficient time,

leadership and policy support, and allotment of resources. Given the large
number of factors that can inhibit EBP implementation efforts (Center for
Deployment Psychology, 2015), no single approach is likely to resolve all the
dissemination and implementation problems. Any successful approach likely
needs to be flexible and multifaceted to address the unique and diverse
challenges each clinic faces when endeavoring to integrate EBPs for the
treatment of PTSD (Stirman et al., 2016). To improve efficiency, interven-
tions designed to increase implementation should address multiple barriers
rather than only one.
A participatory approach can be effective: working closely with clinic
leadership and providers to identify their specific barriers and goals. Addi-
tionally, setting goals and monitoring progress are important throughout
implementation efforts (e.g., Kirchner et al., 2014). In larger networks,
such as the VA or military treatment facilities (MTFs), efforts would prob-
ably benefit from beginning small rather than making large, far-­reaching
changes. These focused efforts can be used to show that implementation
efforts are feasible and effective. Clinics and providers should work to create
an implementation plan that will be effective in their setting, building on
their strengths and addressing their most significant barriers. Finally, it is
imperative that as programs work to disseminate and implement EBPs for
PTSD, they share their successes and lessons learned with other clinics and
programs to expand and improve access to EBPs more generally.
As mentioned, follow-­up studies of providers trained to use EBPs for
PTSD suggest that they do not implement them universally (Borah et al.,
2013; Finley et al., 2015; Rosen et al., 2017) or with complete fidelity (Thomp-
son et al., 2018; Wilk et al., 2013). Furthermore, the study of Bruns and col-
leagues (2016) raises the broader challenge of sustaining implementation
gains. As discussed, a number of efforts face many barriers that must be
overcome to successfully implement EBPs. However, relatively little work
has addressed the factors that interfere with sustainment of implementation
gains once they have been made. It is highly likely that the reasons a clinic or
provider fails to maintain the use of EBPs overlap with the barriers to initial
implementation. That is, if a clinic needed to make organizational changes
to implement treatments, then it is likely that the use of EBPs will be reduced
as a result, should the organizational changes reverse due to a change in
leadership or higher-­level policy. However, it is also possible that factors not
yet identified as barriers to initial implementation can contribute to failures
to sustain the use of EBPS once they have been implemented. Research to
identify these factors and understand how they might function to reduce the
use of EBPs is needed.
Within the PTSD field, the challenges involved in the implementation
and sustainment of EBP use raise additional questions about the nature of
Training and Implementation of Evidence‑Based Psychotherapies 483

the treatments that are identified as first-line therapies for PTSD. On the
whole, these therapies tend to be technique-­driven (e.g., PE, CPT, EMDR
therapy), with delivery following a relatively structured format over a num-
ber of in-­person sessions. None of the individual techniques is particularly
complicated, and the recommended number of sessions is typically lim-
ited. However, the existing treatments that work do require therapists to
learn a new set of skills, patients to commit substantial time and resources
to therapy, and both therapists and patients to approach the emotionally
stressful aftereffects of trauma. In short, the nature of the psychotherapeu-
tic approaches to treating PTSD may make them difficult to sustain. This
raises a challenge as the field of PTSD treatment development progresses.
Perhaps it is important to consider alternative treatment approaches and
delivery strategies (e.g., online therapy) that are designed with questions of
implementation and sustainment in mind as well as their efficacy in treating
PTSD.

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C H A P TE R 2 5

A Health Economics View

Ifigeneia Mavranezouli and Cathrine Mihalopoulos

A ccording to the World Health Organization (WHO) World Mental Health

Surveys, posttraumatic stress disorder (PTSD) has a lifetime prevalence
of 3.9% in the general population, and 5.6% among those exposed to trauma
(Koenen et al., 2017). The mean duration of PTSD symptoms is approxi-
mately 6 years, ranging from about 1 year for symptoms developed following
exposure to a natural disaster to over 13 years following traumas involving
combat experience (Kessler et al., 2017). These data suggest a mean num-
ber of 12.9 PTSD episodes per 100 people in the general population, which
translate into a burden of 77.7 years lived with PTSD per 100 people (Kessler
et al., 2017).
PTSD is associated with substantial levels of disability, loss of quality
of life, and reduced productivity (Alonso et al., 2004). It is often comorbid
with other mental disorders such as depression, substance abuse, other anxi-
ety disorders (Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995), and has
been associated with cardiovascular and metabolic disease (Ahmadi et al.,
2011; Dedert, Calhoun, Watkins, Sherwood, & Beckham, 2010). Despite the
burden associated with PTSD, only a small proportion of people with PTSD
seek treatment for their symptoms, ranging from 23% in low-/lower-­middle-­
income countries to 54% in high-­income countries (Koenen et al., 2017).
Nevertheless, wide literature suggests that people with PTSD consume a con-
siderable amount of health care resources.
People with posttraumatic stress symptoms incur significantly higher
health care costs compared with people without such symptoms, including
costs associated with outpatient visits, emergency department visits, mental
health inpatient stays, physician contacts, and medication (Chan, Medicine,
Air, & McFarlane, 2003; Lamoureux-­Lamarche, Vasiliadis, Preville, & Ber-
biche, 2016; Walker et al., 2003). A U.S. study on Department of Veterans

492
A Health Economics View 493

Affairs patients with depression showed that those with comorbid PTSD
symptoms had more frequent mental health specialty and other outpatient
visits compared with patients with depression without PTSD (Chan, Cheadle,
Reiber, Unutzer, & Chaney, 2009). In another U.S. study, patients with PTSD
were found to incur significantly higher mental health and total health care
costs than those incurred by patients with depression, after adjusting for
baseline characteristics (Ivanova et al., 2011). Using data from the Nation-
wide Inpatient Sample (NIS), the largest all-payer inpatient care database
in the United States, Haviland, Banta, Sonne, and Przekop (2016) estimated
that between 2002 and 2011 there were 1,477,944 hospitalizations with either
a primary or secondary PTSD diagnosis in the United States, costing $34.9
billion (2011 U.S. dollars). In Europe, in 2010 there were an estimated 7.7
million patients with PTSD, incurring health care costs of €8.24 million
(2010 euros) (Gustavsson et al., 2011).
In addition to health care resources, people with PTSD may use social
services and incur costs associated with social worker contacts, rehabilita-
tion, housing, and social benefits. They are also likely to have PTSD-­related
out-of-­pocket expenses and bear costs relating to absenteeism and unem-
ployment. A study conducted in Northern Ireland estimated that in 2008
there were 74,935 individuals with PTSD in Northern Ireland, who incurred
approximately £27.3 million in service costs (including hospitalizations and
visits to health care professionals), £5.7 million in medication costs, and
£139.8 million in reduced productivity (associated with either days of inca-
pacity or reduced productivity while at work) (Ferry et al., 2015). These find-
ings suggest that PTSD imposes a considerable burden on individuals, their
carers and family, health and social care services, and the broader society.

Basic Concepts in Economic Evaluation

of Health Care Interventions

The principle underpinning the development of health economics is the

scarcity of health care resources and the choices that need to be made on
how to best use these limited resources. When resources are used in one
way to provide some form of health benefit, other benefits are forgone
by not using resources in an alternative way (opportunity cost). Economic
evaluation compares both costs and consequences of alternative courses of
action to identify cost-­effective strategies to inform decision making. The
aim of economic evaluation is to achieve optimal allocation of resources in
order to maximize the benefits for the population (Drummnod, Schulpher,
Claxton, Stoddart, & Torrance, 2015). A number of regulatory and advi-
sory bodies worldwide, such as the National Institute for Health and Care
Excellence (NICE) in England (www.nice.org.uk), the Dutch National Health
Care Institute (https://english.zorginstituutnederland.nl), the Norwegian Medi-
cine Agency (https://legemiddelverket.no/English), the Canadian Agency for
494 Application, Implementation, and Future Directions

Drugs and Technologies in Health (CADTH; www.cadth.ca), and the Phar-

maceutical Benefits Advisory Committee (PBAC) in Australia (https://pbac.
pbs.gov.au), incorporate cost-­effectiveness considerations in their appraisals
of health technologies and programs.
Depending on the measure of health outcome used, four broad types
of economic evaluation can be identified: cost-­ effectiveness analysis,
cost–­consequence analysis, cost–­benefit analysis, and cost–­utility analysis
(Drummnod et al., 2015). In cost-­effectiveness analysis, a single outcome
measure is used that is expressed in physical, clinically meaningful units
(e.g., number of lives saved, mean change score on a PTSD symptom scale).
In cost–­consequence analysis, there is no summary measure of health out-
come. Instead, various outcomes associated with the health care strategies
assessed, such as clinical symptoms, acceptability, functioning, and quality
of life, are considered alongside costs. In cost–­benefit analysis, health out-
comes are given a monetary value; this can be determined, for example, by
asking individuals to state the maximum amount of money they are willing
to pay to gain the health benefits accrued by the assessed strategy. Finally,
in cost–­utility analysis, a single summary measure of health outcome is
used, capturing both mortality and morbidity aspects of health. Common
examples of such outcome measures include the quality-­adjusted life year
(QALY), the disability-­adjusted life year (DALY), and the health-­adjusted life
expectancy (HALE). The most commonly used metric is the QALY (Wein-
stein, Torrance, & McGuire, 2009).
QALYs express the amount of time spent by an individual in a health
state, weighted by a utility value representing the “value” of the health-­related
quality of life (HRQoL) relating to this state. Utility values reflect people’s
preferences for health; they measure HRQoL on a scale from 0 (death) to 1
(perfect health). For example, 2 years of life with a HRQoL valued at 0.8 pro-
vide 2 × 0.8 = 1.6 QALYs. By incorporating quantity and quality of life in a
single summary measure, QALYs allow broad cost-­effectiveness comparisons
across strategies aimed at different disease areas and patient populations
(Brazier, Ratcliffe, Salomon, & Tsuchiya, 2017). For this reason, the QALY is
the preferred summary outcome measure for economic evaluation by many
regulatory bodies worldwide that have incorporated cost-­effectiveness con-
siderations in their decision-­making processes (Sassi, 2006). Several studies,
using a variety of validated methods, have translated the HRQoL of people
with PTSD into “preference-­based” utility values that can be used for the
estimation of QALYs (Doctor, Zoellner, & Feeny, 2011; Freed et al., 2009;
Gospodarevskaya, 2013; Haagsma et al., 2012; Mancino et al., 2006).
An alternative measure to the QALY is the DALY, a measure that has
been widely used by the WHO and Institute of Health Metrics in their
evaluation of the global burden of disease (Murray et al., 2012). DALYs
express the number of years lost due to premature mortality or due to dis-
ability (World Health Organization, 2018). The use of DALYs in economic
A Health Economics View 495

evaluation of health care interventions is less common than the use of

QALYs; nevertheless, DALYs are being used in WHO Generalized Cost-­
Effectiveness Analysis studies (Murray, Evans, Acharya, & Baltussen, 2000)
and studies aiming at priority setting in the Australian health care system
(Carter et al., 2008).
The first step in estimating the total costs (that may be incurred or
saved) associated with a health care strategy, service, or intervention is to
determine the perspective of the economic evaluation (Byford & Raftery,
1998). Quite commonly, the adopted perspective is that of the providers
(health service) or payers (e.g., health insurance) of health care; these per-
spectives take into account costs such as medication, health care staff time,
hospitalization, laboratory testing, and the like. Depending on the stake-
holders’ interests and the bodies and individuals affected by the evaluated
strategies, broader perspectives can be used that may include social care
costs, costs falling onto other public bodies (e.g., the criminal justice sys-
tem), out-of-­pocket expenses for patients and families/carers, as well as
indirect costs relating to productivity losses, for example, due to disability,
unemployment, or time off from work (Drummnod et al., 2015). The broad-
est perspective is the societal one; this perspective measures the impact of
an intervention or program on the welfare of the whole society, including
both direct (health care and non-­health care) costs and productivity losses
(Byford & Raftery, 1998). Although adoption of a societal perspective is
broadly advocated (Jonsson, 2009), it has been argued that incorporation of
productivity losses may have equity implications (as it disfavors older adults,
children, and people with disabilities); furthermore, it raises methodologi-
cal issues in terms of quantifying and valuing productivity effects (Knies,
Severens, Ament, & Evers, 2010; Schulper, 2001).
To determine the cost-­effectiveness of a strategy, it is necessary to com-
pare both costs and health outcomes between the strategy and its compara-
tor. When a strategy has lower total costs and higher total benefits than its
comparator, then it is clearly more cost-­effective and is called “dominant.” In
contrast, when a strategy has higher total costs and lower total benefits than
its comparator, it is less cost-­effective and “dominated.” When total costs and
benefits are both higher or both lower than the comparator’s, then they can
be combined in an Incremental Cost-­Effectiveness Ratio (ICER), which is the
difference in costs (DC) divided by the difference in benefits (DB) between
the two strategies, so that

ICER = DC/DB

The decision maker then needs to judge whether the additional (incre-
mental) benefits are worth the incremental costs to determine whether the
evaluated strategy is cost-­effective. For example, NICE in England gener-
ally considers strategies as being cost-­effective when they have an ICER
496 Application, Implementation, and Future Directions

of up to £20,000–£30,000/QALY (National Institute for Health and Care

Excellence, 2013). In Canada, CADTH has not determined an explicit cost-­
effectiveness threshold (Canadian Agency for Drugs and Technologies in
Health, 2017). In Australia, PBAC has also not set an explicit threshold;
however, an implicit threshold of Aus$45,000–$50,000/QALY (or DALY)
is effectively being used (Carter et al., 2008; Edney, Haji Ali, Cheng, & Kar-
non, 2018), whereas in the United States, the American College of Cardiol-
ogy and American Heart Association consider interventions with an ICER
below US$50,000/QALY as highly cost-­effective (Dubois, 2016).
An economic analysis should include all options relevant to a decision
problem, including standard care, and adopt an incremental approach of
analysis, where each option is compared to the next most effective nondomi-
nated option. The option with the highest ICER below the cost-­effectiveness
threshold is the most cost-­effective option.
Economic evaluations can be conducted alongside clinical trials or
observational clinical studies, where the health outcomes and resources
consumed by the study samples are measured in parallel, or by undertak-
ing decision-­analytic economic modeling. Decision-­analytic models are sim-
ulations of alternative care pathways onto hypothetical cohorts of people
(ranging from a single “average” person to an entire population) that allow
the estimation of the relative cost-­effectiveness of different programs over
long time horizons by synthesizing clinical and cost data derived from vari-
ous sources, such as clinical trials, observational studies, patient notes, and
expert opinion (Petrou & Gray, 2011). The robustness of the results of eco-
nomic modeling should be tested in sensitivity analysis, which explores the
impact of different assumptions and of the uncertainty in the model input
parameters on the results and conclusions of the economic analysis (Briggs,
Sculpher, & Buxton, 1994). Probabilistic analysis enables concurrent consid-
eration of uncertainty across all input parameters (Briggs, 1999) and allows
estimation of the probability that an intervention is cost-­effective at different
cost-­effectiveness thresholds (Fenwick, Claxton, & Sculpher, 2001).

Cost‑Effectiveness of Interventions for PTSD

Several studies have assessed the cost-­effectiveness of interventions for peo-

ple with PTSD. The majority of economic evaluations have assessed treat-
ments for adults, but more recently there has been emerging literature on
the cost-­effectiveness of treatments for children and adolescents with PTSD.
The economic studies of treatments for PTSD described in this chapter were
identified by a systematic literature search in the MEDLINE, Embase, and
HTA databases for the period between January 2000 and November 2018,
using combined terms to capture the target condition (PTSD) and terms
relating to economic evaluation. The search did not attempt to identify
A Health Economics View 497

gray literature. In addition, we have included a description of the primary

economic analyses undertaken to inform the NICE 2018 PTSD guideline
update (National Institute for Health and Care Excellence, 2018a). These
analyses were based on clinical data gathered by NICE and therefore may
have taken into account different clinical data from those considered for
the International Society for Traumatic Stress Studies (ISTSS) guidelines
update, due to differences in inclusion criteria and the overall methodology
adopted between the two guidelines. It is thus important to recognize that
this has led to some subtle differences between the NICE recommendations
and those of ISTSS.
An overview of the methods and results of economic studies assess-
ing treatments for PTSD in adults and children/adolescents is provided in
Tables 25.1 and 25.2, respectively.

Interpretation of Economic Evidence:

Implications for Policy and Practice
Summary of Cost‑Effectiveness Findings
Treatments for Adults with PTSD
Limited evidence suggests that a stepped-­care case-­f inding intervention may
be cost-­effective for adults after large-scale trauma. Cognitive-­behavioral
therapy with a trauma focus (CBT-T), prolonged exposure (PE), cognitive
processing therapy (CPT), virtual reality exposure (VRE), and selective sero-
tonin reuptake inhibitors (SSRIs) appear to be cost-­effective relative to no
treatment or treatment as usual (TAU) for adults with PTSD. On the other
hand, collaborative care, group self-­management therapy that includes a
direct behavioral component, and CBT tailored for adults with PTSD and
co-­occurring severe mental illness have been shown to be no more cost-­
effective than either TAU or psychoeducation. PE appears to be more cost-­
effective than sertraline.
According to the only study that explored the relative cost-­effectiveness
across multiple treatment options, brief individual CBT-T (<8 sessions), psy-
choeducation, eye motion desensitization and reprocessing (EMDR) therapy,
combined somatic and cognitive therapies, and self-help with support appear
to be among the most cost-­effective treatment options for adults with PTSD.
In contrast, individual CBT-T >12 sessions, counseling, combined individual
CBT-T and SSRIs, group CBT-T, and present-­centered therapy appear to be
the least cost-­effective options relative to other active treatments. Counsel-
ing and individual CBT-T >12 sessions may be less cost-­effective than no
treatment. In between, there are other, “moderately” cost-­effective options
such as SSRIs, individual CBT-T 8–12 sessions, self-help without support,
CBT without a trauma focus, and interpersonal psychotherapy (IPT).
498
TABLE 25.1. Overview of the Methods and Results of Economic Evaluations of Interventions for Adults with PTSD
Type of economic evaluation
Measure of outcome Perspective
Study design and source of Cost elements
Study efficacy data Cost-effectiveness results
Currency and cost
Country Time horizon Study population Interventions compared year Uncertainty

Cohen et al. Cost-effectiveness and cost- Hypotheti- • Stepped-care case-find- Health care sector Stepped care vs. TAU:
(2017) utility analysis cal cohort of ing intervention and $0.80–1.61/PTSD-free day
Therapists’ time
individuals living early treatment: cases
U.S. Number of PTSD-free days $3,429–6,858/DALY averted
in hurricane- were referred to CBT; U.S. dollars, likely
and DALY
affected areas of noncases were referred 2012 (Ranges derived from different
Decision-analytic modeling; New York City to SPR, an evidence- assumptions regarding costs of
diagnostic characteristics: informed therapy that CBT and SPR.)
assumption; efficacy: pub- aims to reduce distress
Results robust to use of a range
lished studies and improve coping and
of values for sensitivity and
functioning
10 yr specificity (0.80–1).
• TAU; all patients were
referred to SPR

Dunn et al. Cost-consequence analysis Male veterans • Group self-management Health service Self-management therapy
(2007) with chronic therapy that included resulted in similar costs and
PTSD symptoms measured Psychiatric, medical,
combat-related a direct behavioral outcomes with psychoeduca-
U.S. by CAPS and DTSS; depres- and surgical care;
PTSD and depres- component tion.
sive symptoms measured medication
sive disorder • Group psychoeducation
by the 18-item HAMD and
U.S. dollars, 1999
BDI-II, treatment compli-
ance, satisfaction with treat-
ment, treatment-targeted
constructs, functioning mea-
sured by the BSI and ASI
RCT (N = 101)
12 mon
 Le, Doctor, Cost-utility analysis Adults with PTSD • Prolonged exposure Societal Prolonged exposure was domi-
Zoellner, & • Sertraline nant over sertraline in both
QALY Therapists’ time,
Feeny (2014) RCT and preference trial (bet-
medication, out-
RCT (N = 103) and prefer- ter outcomes, lower costs).
U.S. patient care and
ence trial (N = 97)
inpatient care, emer- Probability of prolonged
12 mon gency department, exposure being cost-effective at
pharmacy and other a cost-effectiveness threshold
supportive services, of $100,000/QALY: 0.93 (range
productivity losses due 0.91–0.95, for use of highest
to time spent in treat- and lowest estimates of unit
ment and travel time costs, respectively); at zero
to/from clinic WTP, 0.60.
U.S. dollars, 2012

Meyers et al. Cost-effectiveness analysis Veterans with • Prolonged exposure or Health service Prolonged exposure or CPT
(2013) combat-related CPT was dominant over no treat-
PCL–military version score Mental health care,
PTSD or symp- • No treatment ment (better outcomes, lower
U.S. and BDI-II primary care, emer-
toms of PTSD costs).
gency department
Before–after study (N = 70)
Difference in costs and
U.S. dollars, cost year
12 mon outcomes was statistically
not reported
significant.

Mihalopoulos Cost-utility analysis Prevalent cases of 1st comparison: Health sector (govern- 1st comparison:
et al. (2015) adults with PTSD • CBT-T replacing or ment and patients’ out- CBT-T vs. TAU:
QALY and DALY
in Australia in added on TAU of-pocket expenses) $19,000/QALY; $16,000/DALY
Australia
Decision-analytic economic 2012, in receipt • TAU (non-evidence- averted
Psychologists’ and
modeling; systematic review of non-evidence- based care comprising
GPs’ time; medication Probability of CBT-T being
and meta-analysis of RCTs based care consultation with health
care professionals) cost-effective: 1.00 at a cost-
Australian dollars,
5 yr effectiveness threshold of
2012
$50,000/QALY

(continued)

499
500
TABLE 25.1. (continued)
Type of economic evaluation
Measure of outcome Perspective
Study design and source of Cost elements
Study efficacy data Cost-effectiveness results
Currency and cost
Country Time horizon Study population Interventions compared year Uncertainty

Mihalopoulos
et al. (2015) Results most sensitive to
(continued) changes in utility scores, par-
ticipation rates, adherence to
treatment, likelihood of being
offered CBT and effectiveness

2nd comparison: 2nd comparison:

• SSRIs replacing or SSRIs vs. TAU: $230/QALY;
added on TAU ICER for DALYs averted not
• TAU (non-evidence- reported
based medication) Probability of SSRIs being
dominant: 0.27
Results most sensitive to
changes in utility scores and
participation rates

National Cost-utility analysis Adults with PTSD • Combined somatic and NHS and PSS All interventions except CBT-T
Institute or clinically cognitive therapies individual <8 sessions and psy-
QALY Psychologists’ time,
for Health important symp- • Counseling choeducation were dominated
inpatient and outpa-
and Care Decision-analytic economic toms of PTSD • EMDR therapy by one or more interventions.
tient care, primary
Excellence modeling; systematic review • CBT without a trauma CBT-T individual <8 sessions
and community care,
(2018c) and NMA of RCTs focus vs. psychoeducation £9,208/
social services, medi-
• IPT QALY
UK 3 yr cation
• Present-centered
therapy GBP, 2017
 • Psychoeducation Ranking of interventions by
• Self-help with support cost effectiveness (at a cost-
• Self-help without sup- effectiveness threshold of
port £20,000/QALY):
• SSRI • CBT-T individual <8 sessions
• CBT-T individual <8 • Psychoeducation
sessions • EMDR therapy
• CBT-T individual 8–12 • Combined somatic and cog-
sessions nitive therapies
• CBT-T individual >12 • Self-help with support
sessions • SSRI
• CBT-T group 8–12 ses- • SH without support
sions • CBT-T individual 8–12 ses-
• CBT-T individual 8–12 sions
sessions + SSRI • IPT
• No treatment • CBT without a trauma focus
• Present-centered therapy
CBT-T class included a • CBT-T group 8–12 sessions
range of interventions, • CBT-T individual 8–12 ses-
such as cognitive sions + SSRI
processing therapy, • No treatment
CBT-T, cognitive therapy • CBT-T individual >12 ses-
for PTSD, cognitive sions
restructuring and imagery • Counseling
modification, narrative • Probability of CBT-T indi-
exposure, and prolonged vidual <8 sessions being the
exposure most cost-effective option:
0.28
Results robust to changes in
the risk of relapse, changes in
PTSD costs, use of alternative
utility values, and different
assumptions on the effect
beyond 3 mon posttreatment
(continued)

501
502
TABLE 25.1. (continued)
Type of economic evaluation
Measure of outcome Perspective
Study design and source of Cost elements
Study efficacy data Cost-effectiveness results
Currency and cost
Country Time horizon Study population Interventions compared year Uncertainty

Schnurr et al. Cost-consequence analysis Veterans with • Collaborative care Health service Collaborative care was domi-
(2013) PTSD • TAU nated by standard care (higher
Primary: PTSD symptom Outpatient visits
costs and similar or worse
U.S. severity, measured using including interven-
outcomes).
the PDS tion, outpatient phar-
macy, inpatient care No significant differences in
Secondary: depression mea-
(including pharmacy), outcomes, except in perceived
sured using the HSCL-20;
and fee-for-service quality of PTSD care, where
functioning using the SF-12;
care collaborative care had a worse
perceived quality of PTSD
rating than TAU.
care and overall care U.S. dollars, 2010
RCT (N = 195)
6 mon

Slade et al. Cost-effectiveness analysis Adults with • CBT tailored for adults Public mental health CBT vs. breathing retrain-
(2017) severe PTSD and with PTSD and co- system ing and psychoeducation:
Rate of PTSD remission
co-occurring occurring severe mental $36,893/PTSD remission
U.S. (loss of clinical criteria for Therapists’ time, men-
severe mental illness
PTSD based on CAPS) tal health inpatient, Probability of CBT being cost-
illness (major • Breathing retraining
outpatient, and emer- effective at a cost-effectiveness
RCT (N = 201) mood disorder, and psychoeducation
gency department threshold of $50,000/PTSD
schizophrenia, or
12 mon care, psychotropic remission: approx. 0.52
schizoaffective
medication
disorder)
U.S. dollars, 2010
 Tuerk et al. Cost-effectiveness analysis Veterans with • Prolonged exposure Mental health service Prolonged exposure was domi-
(2013) combat-related • No treatment nant over no treatment (better
PCL–military version score Mental health care
PTSD outcomes, lower costs).
U.S. including interven-
Before–after study (N = 60)
tion, medicine Difference in outcomes was
12 mon management, psycho- statistically significant; level of
therapy, supportive significance of difference in
counseling, motiva- costs not reported.
tional interviewing,
case management,
and other relevant
resource use; primary
care costs were
excluded
U.S. dollars, 2009

Wood et al. Cost-consequence analysis Military staff with • Virtual reality exposure Military system Virtual reality exposure
(2009) combat-related therapy therapy was dominant over
PCL–military version score; Therapists’ time
PTSD • TAU TAU (better outcomes, lower
U.S. PHQ-9; BAI (assessment and inter-
costs).
vention), military staff
Synthesis of data from
training (required
multiple sources; noncom-
to replace staff who
parative study (N = 12) for
would be medically
intervention effects; no
discharged from duty
modeling conducted
due to the severity of
2 yr their PTSD, if nonre-
covered)

Note: ASI, Addiction Severity Index; BAI, Beck Anxiety Inventory; BDI, Beck Depression Inventory; BSI, Brief Symptom Inventory; CAPS, clinician-administered PTSD Scale;
CBT, cognitive-behavioral therapy; CBT-T, cognitive-behavioral therapy with a trauma focus; CPT, cognitive processing therapy; DALY, disability-adjusted life year; DTSS, David-
son Traumatic Stress Scale; EMDR, eye movement desensitization and reprocessing therapy; HAMD, Hamilton Depression Rating Scale; HSCL, Hopkins Symptom Checklist;
ICER, incremental cost-effectiveness ratio; NHS, National Health Service; NMA, network meta-analysis; PCL, PTSD Check List; PDS, Posttraumatic Diagnostic Scale; PHQ,
Patient Health Questionnaire; PSS, personal social services; QALY, quality-adjusted life year; RCT, randomized clinical trial; SF, short form; SPR, Skills for Psychological Recov-
ery; SSRI, selective serotonin reuptake inhibitor; TAU, treatment as usual.

503
504
TABLE 25.2. Overview of the Methods and Results of Economic Evaluations of Interventions for Children and Adolescents with PTSD
Type of economic
evaluation
Measure of outcome
Perspective
Study design and
Study source of efficacy data Cost elements Cost-effectiveness results
Country Time horizon Study population Interventions compared Currency and cost year Uncertainty

Aas, Iversen, Cost-utility analysis Young people • CBT-T Health service CBT-T was dominant over TAU
Holt, Ormhaug, & (10–18 years of • TAU (more effective and less costly).
QALY Therapists’ time
Jensen (2018) age) presenting
Probability of CBT-T being
RCT (N = 156) with symptoms of Norwegian krone, 2018
Norway cost-effective at a zero cost-
PTS
2 yr effectiveness threshold: 0.96

Gospodarevskaya Cost-utility analysis Children who met • CBT-T Mental health service Counseling was dominated by
& Segal (2012) all or most of the • CBT-T + SSRI CBT-T (less effective and more
QALY Therapists’ time (psy-
DSM-IV PTSD • Nondirective support- costly).
Australia chologist, psychiatrist,
Decision-analytic eco- diagnostic criteria ive counseling
GP, social worker), medi- CBT-T + SSRI vs. CBT-T
nomic modeling; meta- including at least • No treatment
cation, parental group, $2,901/QALY
analysis of RCTs and one symptom
or psychoeducational
indirect comparisons of avoidance or CBT-T vs. no treatment $1,650/
sessions
reexperiencing; QALY
31 yr some had Australian dollars, 2011
comorbid Results sensitive to variation in
depression clinical effectiveness
 McCrone et al. Cost-consequence Sexually abused • Individual psychoana- Mental health services Individual therapy was
(2005) analysis girls (6–14 lytical psychotherapy significantly more costly than
Therapists’ time
years old) with + support to parents group therapy.
UK Symptoms of PTSD
symptoms of • Group psychotherapy GBP, 1999
using Orvaschel’s PTSD No statistically significant dif-
emotional or (with psychotherapeu-
scale; global impair- ference in PTSD symptomatol-
behavioral tic and psychoeduca-
ment of functioning ogy or in global impairment of
disturbance, 73% tional components) +
using the K-SADs and functioning between inter-
of whom had PTSD support to parents
K-GAS ventions; individual therapy
showed significantly greater
RCT (N = 75)
improvements in manifesta-
2 yr tions of PTSD compared with
group therapy.

Mihalopoulos et Cost-utility analysis Prevalent cases • CBT-T replacing or Health sector CBT-T vs. TAU: $8,900/QALY;
al. (2015) of children and added on TAU (government and $8,000/DALY averted
QALY and DALY
adolescents with • TAU (non-evidence- patients’ out-of-pocket Probability of CBT-T being
Australia
Decision-analytic PTSD in Australia based care compris- expenses) cost-effevctive at a cost-
economic modeling; in 2012, in receipt ing consultation with effectiveness threshold of
Psychologists’ and GPs’
systematic review and of non-evidence- health care profes- $50,000/QALY: 0.99
time
meta-analysis of RCTs based care sionals)
Australian dollars, 2012 Results most sensitive to PTSD
5 yr prevalence, effectiveness,
adherence, and the likelihood
of being considered eligible for
CBT-T

(continued)

505
506
TABLE 25.2. (continued)
Type of economic
evaluation
Measure of outcome
Perspective
Study design and
Study source of efficacy data Cost elements Cost-effectiveness results
Country Time horizon Study population Interventions compared Currency and cost year Uncertainty

National Institute Cost-utility analysis Children and • Cohen CBT-T/CPT NHS and PSS CT-PTSD was dominant over
for Health and adolescents with (CBT-T) all other interventions (less
QALY Psychologists’ time,
Care Excellence PTSD or clinically • CT-PTSD (CBT-T) costly and more effective).
inpatient and outpa-
(2018b) Decision-analytic important • EMDR therapy Ranking of interventions by
tient care, ambulance,
economic modeling; symptoms of PTSD • Family therapy cost effectiveness (at a cost-
UK emergency department,
systematic review and • Group CBT-T (CBT-T) effectiveness threshold of
community staff, advice
NMA of RCTs • Narrative exposure £20,000/QALY):
service, social services,
(CBT-T) • CT-PTSD
3 yr medication
• Parent training • Narrative exposure
• Play therapy GBP, 2017 • Play therapy
• Prolonged exposure • Prolonged exposure
(CBT-T) • Cohen CBT-T/CPT
• Supportive counseling • EMDR therapy
• No treatment • Parent training
• Group CBT
• Family therapy
• Support counseling
• No treatment
Probability of CT-PTSD being
the most cost-effective option:
0.78
Results robust to changes in
the risk of relapse and use of
alternative utility data
 Salloum et al. Cost-consequence Young children • Stepped-care CBT-T Societal (health care Stepped-care CBT-T similar
(2016) analysis (aged 3–7 years) • Standard CBT-T system and parents’ to standard CBT-T regarding
experiencing PTS productivity losses) outcomes (less effective in
U.S. Primary: trauma
symptoms CBCL externalizing T-scores)
symptoms measured Therapists’ time, par-
and less costly
using the TSCYC, PTS ents’ productivity losses
subscale
U.S. dollars, likely 2011
Secondary: CGI-S;
CGI-I; CBCL; DIPA;
treatment credibility
and satisfaction;
parents’ assessment of
PTSD diagnosis
RCT (N = 53)
3 mon

Shearer et al. Cost-utility analysis Children and • CT-PTSD NHS and PSS CT-PTSD vs. wait list: £2,205/
(2018) adolescents aged • Wait list QALY
QALY Psychologists’ time,
8–17 years, who Probability of CT-PTSD
UK inpatient and outpa-
RCT (N = 29) and had experienced being cost-effective at a
tient care, ambulance,
extrapolation using a single traumatic cost-effectiveness threshold
emergency department,
decision-analytic eco- event in the of £20,000–30,000/QALY,
community staff, advice
nomic modeling previous 2–6 respectively: 0.60–0.69
service, social services,
mon and met
3 yr medication Conclusions on cost-effective-
age-appropriate
diagnosis of PTSD GBP, 2014 ness robust to completer case
analysis and to inclusion of
psychologist training costs

Note: CBCL, Child Behavior Checklist; CBT-T, cognitive-behavioral therapy with a trauma focus; CGI-I, Clinical Global Impression—Improvement; CGI-S, Clinical Global Impres-
sion—Severity; CPT, cognitive processing therapy; CT-PTSD, cognitive therapy for PTSD; DALY, disability-adjusted life year; DIPA, Diagnostic Infant and Preschool Assessment;
EMDR, eye movement desensitization and reprocessing therapy; K-GAS, Kiddie Global Assessment Scale; K-SADs, Kiddie Schedule for Affective Disorders and Schizophrenia
scale; NHS, National Health Service; NMA, network meta-analysis; PTS, posttraumatic stress; PSS, personal social services; QALY, quality-adjusted life year; RCT, randomized
clinical trial; SSRI, selective serotonin reuptake inhibitor; TAU, treatment as usual; TSCYC, Trauma Symptom Checklist for Young Children.

507
508 Application, Implementation, and Future Directions

Treatments for Children and Adolescents with PTSD

For children and adolescents with PTSD, evidence indicates that CBT-T,
stepped-­care CBT-T, and cognitive therapy for PTSD (CT-PTSD) are likely
to be cost-­effective compared with no treatment or TAU. Group psychother-
apy may be more cost-­effective than individual psychotherapy. Combination
therapy consisting of CBT-T and SSRIs appears to be more cost-­effective
than CBT-T alone in children with PTSD and possible comorbid depression.
Regarding the relative cost-­ effectiveness across multiple treatment
options, individual forms of CBT-T and, to a lesser degree, play therapy
appear to be most cost-­effective in the treatment of children and adolescents
with PTSD, followed by EMDR therapy, parent training, and group CBT-T,
with family therapy and supportive counseling being the least cost-­effective
treatments. Nevertheless, all these treatments are likely to be more cost-­
effective than no treatment for children and adolescents with PTSD.

Limitations of the Existing Evidence Base

Current economic evidence covers primarily the cost-­effectiveness of treat-
ments for adults, children, and young people with PTSD. There is very lim-
ited or nonexistent economic evidence for prevention and early intervention.
Moreover, the evidence comes from a small number of developed countries
(primarily the United States, but also the United Kingdom, Norway, and
Australia); no evidence is available on the cost-­effectiveness of treatments
for people with PTSD in developing countries.
The majority of reviewed economic evaluations have included a limited
number of treatment options, with a focus on CBT-T and its various forms,
with other evidence-­based treatments having been largely ignored in this
literature. For example, the cost-­effectiveness of EMDR therapy in adults
and children/adolescents with PTSD has been assessed only in two analyses
that informed national guidance in England (National Institute for Health
and Care Excellence, 2018b, 2018c), despite the relatively wide evidence base
on its clinical effectiveness, in particular among adults. Moreover, the vast
majority of economic studies made comparisons of one active intervention
with no treatment or TAU, or they made comparisons among a very limited
number of active treatments. Although this may be reasonable in a single-­
intervention decision context (particularly when the comparator is TAU,
which should theoretically include the mix of options currently being used),
it can lead to a suboptimal allocation of resources if the new intervention is
likely to displace another intervention that has not been formally considered
in the evaluation.
To ensure efficient use of available resources, economic evaluations
should assess the relative cost-­effectiveness of the interventions or care likely
to be displaced by adoption of the new intervention. The most appropriate
comparator is likely to change in different decision contexts, and one of the
A Health Economics View 509

hallmarks of good economic evaluations is ensuring that the appropriate

comparators are used for each decision problem. If no interventions or care
is likely to be displaced, then an appropriate comparator may be “no treat-
ment.” Unfortunately, many studies do not explicitly address whether the
comparator is the mix of services likely to be displaced. Ideally, the assess-
ment of the cost-­effectiveness of a new intervention should also take into
account any other new interventions that could, in principle, replace the mix
of options currently forming TAU, by being implemented in addition to, or
instead of, the new intervention of interest.
As can be seen from Tables 25.1 and 25.2, a large number of economic
studies were conducted alongside randomized clinical trials (RCTs; 4/10 in
adults and 4/7 in children/adolescents). Although these studies were of rea-
sonable quality as suggested by their study design, most of them included
a small number of participants and had relatively short time horizons that
did not allow long-term outcomes and costs further down the care path-
way to be considered and incorporated into the cost-­effectiveness estimates.
Therefore, their results should be replicated before robust conclusions can
be drawn. However, one trial-based analysis extrapolated results beyond
the trial endpoint, using decision-­analytic modeling, and considered costs
and benefits over a period of 3 years (Shearer et al., 2018). More important
limitations characterize three economic studies in adults that used a before–­
after or noncomparative study design, as these designs are subject to bias.
Regarding model-based studies (3/10 in adults and 3/7 in children/
adolescents), their quality depends on the assumptions used to structure
and populate the models, sources of data, and methods of evidence syn-
thesis, as well as the time horizon and ability to incorporate longer-­term
costs and outcomes. All model-based economic studies that assessed treat-
ments for people with PTSD derived efficacy data from a review and meta-­
analysis of RCTs and had long time horizons, ranging from 3 to 31 years.
The economic analyses that were conducted to inform national guidelines
in England (National Institute for Health and Care Excellence, 2018b, 2018c)
employed network meta-­analytic (NMA) techniques for synthesis of the effi-
cacy data. This approach considers information from both direct and indi-
rect comparisons between interventions and allows simultaneous inference
on multiple treatment options examined in RCTs while preserving random-
ization (Caldwell, Ades, & Higgins, 2005; Mavridis, Giannatsi, Cipriani,
& Salanti, 2015). The simulation study on the stepped-­care early interven-
tion (Cohen et al., 2017) derived clinical data from a mixture of published
studies and assumptions, and therefore results should be interpreted with
greater caution, although sensitivity analysis examined the impact of differ-
ent assumptions on the results.
Most of the studies utilized a health care perspective, often focusing
on mental health care costs. The studies conducted in the United King-
dom included personal social service costs in their assessment and another
two studies reported adopting a societal perspective, which, in addition to
510 Application, Implementation, and Future Directions

health care costs, included productivity losses. A number of studies consid-

ered only intervention costs as part of the health care perspective; however,
people with PTSD may consume additional health care resources, such as
emergency department, outpatient, and day care, which may be reduced
following provision of effective interventions. Moreover, none of the studies
included wider public-­sector costs, such as those relating to rehabilitation,
housing, and social benefits. However, it is likely that more effective inter-
ventions for PTSD improve social functioning and generate broader benefits
for people with PTSD that are likely to create cost savings in other sectors
beyond health care. Therefore, it is possible that the cost-­effectiveness of
effective treatments for PTSD has been underestimated in the current lit-
erature. Future research should address limitations and gaps in existing eco-
nomic evidence.

Cost‑Effectiveness of Providing Evidence‑Based Treatments

One of the economic studies considered the cost-­effectiveness of the imple-
mentation of Australian guidelines on the treatment of PTSD relative to
TAU, which consisted of non-­ evidence-­based care (Mihalopoulos et al.,
2015). People receiving evidence-­based interventions (who made up only a
small part of the population receiving care for PTSD) were not considered
in this analysis, as the decision context was to evaluate the costs and ben-
efits of moving from non-­evidence-­based to evidence-­based treatment at a
population level. The study concluded that all evidence-­based interventions
that had been recommended in the Australian guidelines and were assessed
in the analysis, that is, CBT-T and SSRIs for the treatment of PTSD in
adults and CBT-T for the treatment of PTSD in children, were cost-­effective
compared to non-­evidence-­based TAU in Australia. This finding is in line
with the findings of similar modeling studies concluding that the optimal,
evidence-­based treatment of anxiety disorders, including PTSD, would be
cost-­effective compared with TAU in Australia (Issakidis, Sanderson, Corry,
Andrews, & Lapsley, 2004) and that universal access to evidence-­based treat-
ment for veterans with PTSD or depression would lead to substantial ben-
efits and associated cost savings (Kilmer, Eibner, Ringel, & Pacula, 2011).

The Role of Economic Evidence in the Context

of Guideline Development
Two of the analyses that evaluated the relative cost-­effectiveness of treat-
ments for PTSD in adults, as well as in children and adolescents (National
Institute for Health and Care Excellence, 2018b, 2018c), informed the
development of national clinical guidelines in England (National Institute
for Health and Care Excellence, 2018a). NICE guidelines consider explic-
itly cost-­effectiveness as one of the criteria for making practice recommen-
dations. Economic analyses conducted within the NICE decision-­making
A Health Economics View 511

context should include, when possible, comparisons of all relevant alterna-

tives and employ an incremental approach (National Institute for Health
and Care Excellence, 2014). Therefore, the economic analyses undertaken
to support the development of NICE PTSD guidelines included the entire
spectrum of interventions available for PTSD, for which adequate evidence
was available to inform economic modeling. The committee that developed
the NICE PTSD practice recommendations considered the cost-­effectiveness
results and additional factors when formulating those recommendations,
such as the quality and breadth of the evidence base across a variety of clini-
cal outcomes for each intervention; the uncertainty characterizing some of
the findings; the range of the severity of PTSD and the type of trauma in par-
ticipants in the RCTs that informed the economic analysis; any populations
for which interventions were ineffective or unsuitable; and patient prefer-
ences. Subsequently, the committee made strong (“offer”) recommendations
for the most cost-­effective treatments that had a robust clinical evidence
base (CBT-T for adults and children; EMDR therapy for adults); weaker
(“consider”) recommendations (supported computerized CBT-T, CBT with-
out a trauma focus, and SSRIs for adults; EMDR therapy for children) or
a research recommendation (emotional freedom technique for adults) for
treatments that were relatively less cost-­effective and/or had a more limited
clinical evidence base; and no recommendations for treatments that were
shown to be the least cost-­effective in the guidelines’ economic analysis and/
or had a very limited clinical evidence base. Some of the treatments were
recommended for specific subgroups, following interpretation of available
clinical and economic evidence and the committee’s considerations on the
suitability of interventions:

• EMDR therapy was recommended for adults with non-­combat-­related

trauma only.
• “Consider” recommendations were made for:
| EMDR therapy in children and adolescents ages 7–17 years who do
not respond to or engage with CBT-T.
| Supported computerized CBT-T in adults who prefer it to face-to-
face CBT-T or EMDR therapy as long as they do not have severe
PTSD symptoms, in particular dissociative symptoms, and are not
at risk of harm to themselves or others.
| CBT without a trauma focus targeted at specific symptoms such
as sleep disturbance or anger in adults who are unable or unwill-
ing to engage in a trauma-­focused intervention or have residual
symptoms after a trauma-­focused intervention (National Institute
for Health and Care Excellence, 2018a).

In conclusion, economic evidence played an important role in support-

ing the development of NICE guideline recommendations but was consid-
ered alongside the quality and limitations of the clinical evidence base as
512 Application, Implementation, and Future Directions

well as patient-­related issues. More generally, a wider range of issues under-

pin NICE guideline recommendations, such as ethical issues, equity consid-
erations, policy imperatives, and equality legislation (National Institute for
Health and Care Excellence, 2014).

Cost‑Effectiveness Considerations in the Context

of the ISTSS Guidelines: Generalizability and Transferability
of Existing Cost‑Effectiveness Findings to Other Settings
Cost-­effectiveness was not explicitly considered in the development of ISTSS
guidelines. Nevertheless, existing economic evidence supports all ISTSS
strong recommendations on treatments for adults (CPT, CT, EMDR therapy,
CBT-T, PE), children and adolescents (CBT-T and EMDR therapy), and most
ISTSS standard recommendations on treatments for adults (CBT without
a trauma focus, guided Internet-­based CBT-T, narrative exposure therapy),
with the exception of group CBT-T and present-­centered therapy, which are
recommended as options in the ISTSS guidelines but have been found to
be less cost-­effective than other active interventions (but nevertheless have
been shown to be more cost-­effective than no treatment). Current cost-­
effectiveness findings also support the ISTSS low effect recommendation
for SSRIs in adults. Interestingly, but perhaps not unexpectedly, interven-
tions with emerging or insufficient evidence are generally not cost-­effective
according to existing evidence. Overall, the implementation of ISTSS guide-
lines appears to ensure efficient use of resources and thus can be expected
to be cost-­effective, although determining an intervention’s cost-­effectiveness
depends on the setting in which the intervention is provided and the adopted
perspective (e.g., that of the provider, payer, government, or society).
Available studies indicate the cost-­effectiveness of interventions in the
specific settings within which the studies were conducted. To judge whether
results are transferable to different countries and settings, one needs to
consider the similarities and differences across settings regarding the study
population characteristics, the funding arrangements and structure of the
services for people with PTSD including access to treatment and designated
care pathways, the intensity of resource use and unit prices, and wider imple-
mentation issues. Another issue to consider is the range of treatment options
available in different settings, as the availability of different options may alter
the relative cost-­effectiveness of interventions, and also the similarities and
differences of TAU, which was the comparator in many of the studies. An
evidence-­based intervention may be cost-­effective relative to TAU that com-
prises basic, non-­evidence-­based care, but may not be so in a setting where
TAU consists of alternative effective interventions. Moreover, assessing the
cost-­effectiveness of an intervention depends on the perspective adopted: for
example, a health care intervention with benefits beyond health (e.g., a reha-
bilitation program that improves social functioning and reduces the need
for costly social care interventions) may not be cost-­effective from a pure
A Health Economics View 513

health care perspective, but may be cost-­effective from a wider health and
social services perspective. Finally, conclusions on cost-­effectiveness rely on
the cost-­effectiveness threshold adopted by policymakers, and this depends
on the policymakers’ willingness to pay for treatment benefits, which may
vary across countries and health systems.

Conclusions

PTSD is associated with significant psychological and financial burdens for

the patients, their family and carers, and wider society. Assessment of cost-­
effectiveness contributes to optimal allocation of health care resources and
maximization of the benefits for the population. Available evidence suggests
that a range of interventions are cost-­effective in the treatment of people
with PTSD. However, existing evidence is characterized by limitations and
gaps that should be addressed in future research. In addition to clinical and
cost-­effectiveness considerations, other factors such as ethical issues, equity,
legislation, policy, and implementation aspects should be considered when
making decisions on the allocation of health care resources.

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C H A P TE R 2 6

The Future of
Traumatic Stress Treatments
Time to Grasp the Opportunity

David Forbes, Jonathan I. Bisson, Candice M. Monson,

and Lucy Berliner

Trepresent
he Posttraumatic Stress Disorder Prevention and Treatment Guidelines advanced
by the International Society for Traumatic Stress Studies (ISTSS) in 2018
a substantial step forward in our understanding of the most effec-
tive strategies to assist people whose lives have been affected by the experi-
ence of trauma and disaster. The chapters in this book have taken those
guidelines to the next level, focusing on what they mean for mental health
providers in clinical practice, how to implement the recommendations, what
to do when treatment does not go as planned, and what the future may hold
in each area. Although the research data provide much cause for optimism,
it is also clear that substantial gaps in our knowledge still exist. Building on
the platform of our solid knowledge base, it is now time for the field to grasp
this opportunity and to confront the challenges raised in the preceding
chapters in this volume. While retaining a solid commitment to evidence-­
based practice, we need to take the field beyond studies of a small number of
specific interventions with defined populations to explore the broad critical
underlying issues. A better understanding of these underpinnings will drive
future developments in an integrated and coherent manner, increasing our
chances of further enhancing improvements in the prevention and manage-
ment of posttraumatic stress disorder (PTSD) and related conditions.
This chapter explores some of the themes raised in the preceding chap-
ters, attempting to elucidate what they mean for our understanding of the
field and the key research, clinical, and systemic implications for the com-
ing years. The themes include the need for more sophisticated approaches
to understanding the nature and course of human response to trauma, the

518
The Future of Traumatic Stress Treatments 519

mechanisms underlying those different trajectories, how best to improve our

treatments, and challenges for implementing best-­ practice interventions.
Running across all those themes is the crucial question of how to better
match specific interventions to the unique needs of each individual.

The Nature and Course

of Traumatic Stress Reactions

Several of the preceding chapters highlight the need for a better understand-
ing of the many ways in which human beings respond to the experience
of a potentially traumatic event, both within and beyond the construct of
PTSD. Increased computing power through machine learning and artificial
intelligence (AI) provides the opportunity to explore different trajectories
in large populations exposed to the same or similar traumatic events. It
is clear that some people show little or no adverse reaction, whereas oth-
ers appear to develop problems immediately following the experience that,
if left untreated, remain over the long term. Although those two groups
are relatively easily identified, alternative trajectories present a greater chal-
lenge. Some people exposed to potentially traumatic events, for example,
develop clinically significant acute reactions but appear to recover over the
coming months, apparently with little or no external assistance. Others may
report low levels of symptomatology, but steadily recruit symptoms over time
to end up crossing the diagnostic threshold; for others, the course fluctu-
ates and some experience symptoms with a delayed onset. It is reasonable
to assume that each trajectory would benefit from a different approach to
intervention in terms of, for example, timing, dose, type, and mode of deliv-
ery, but we can only tailor that assistance to individual need if we can predict
the likely course and maintain active surveillance.
The initial chapters of this volume discuss the challenges ahead for epi-
demiology in developing tools to improve our ability to identify persons at
risk of PTSD and related conditions, not only in the acute phases but also
over the longer term. At present, we know that early PTSD symptom severity
is a strong predictor of later PTSD, but we still cannot confidently predict
which trajectory a trauma survivor will take. Our current screening instru-
ments struggle at identifying those on other trajectories, including those
who may remain “subsyndromal” but nevertheless experience substantial
distress and functional impairment. If we can reliably determine the predic-
tors of different trajectories—­t he risk factors, risk indicators, and protective
factors—­we will have the capacity to develop more effective screening and
assessment strategies to ensure that adults, youth, and children are identi-
fied appropriately and offered the level and type of intervention they require
at the appropriate juncture.
Not only are there substantial differences across individuals in the
course of response and recovery following trauma, but also in the nature of
520 Application, Implementation, and Future Directions

the clinical presentation. As discussed in Chapter 22, mental health prob-

lems following trauma exposure are by no means limited to PTSD, with a
range of comorbid conditions and personality factors commonly present.
Indeed, many of these conditions, such as depression, anxiety, and sub-
stance use disorders, may develop in the aftermath of trauma independently
of, and in the absence of, PTSD. Although much research has explored the
impact of those comorbidities on PTSD treatment response following spe-
cific evidence-­based interventions, the field has room to grow in addressing
the question of how to adapt treatment when other conditions, or symptoms,
are present. This may not simply be a question of adding or integrating
another treatment (e.g., in substance use disorder) alongside the standard
PTSD intervention. Rather, it may be about developing a more personal-
ized and integrated approach to treatment designed to treat the specific
constellations of symptoms (possibly networks of symptoms) with which the
individual presents across a series of co-­occurring conditions and associated
features.
Recent developments in the diagnostic classification systems offer a spe-
cific example of this dilemma. The DSM-5 diagnosis takes a broad approach
to describing the clinical picture of PTSD, with a wide variety of presenta-
tions all potentially coming under the same rubric. While the diagnosis pro-
vides a comprehensive clinical description, it is reasonable to assume that dif-
ferent variations of the disorder subsumed within this single diagnosis may
respond differently to a specific treatment. ICD-11 has taken an alternative
approach, adopting a very narrow definition of PTSD and introducing the
new diagnosis of complex PTSD (CPTSD). This divergence in the diagnostic
criteria for PTSD is discussed in Chapter 4, which highlights the fact that the
two classification systems are no longer interchangeable and discusses the
implications. Certainly, it provides an intriguing basis for future research.
There are now therefore effectively three PTSD diagnoses across ICD and
DSM, albeit one CPTSD. Do the DSM-5 and ICD-11 PTSD diagnoses repre-
sent different constructs, or is one subsumed within the other? Do they show
different trajectories? How do each of these two PTSD diagnoses differen-
tially interdigitate with the CPTSD diagnosis? Do they respond differently to
our existing treatments and do they require different approaches?
Putting all this together, it is clear that, to more accurately tailor inter-
ventions to the specific needs of the individual, we need a more sophisti-
cated understanding of the range of responses to trauma, both in terms
of clinical presentation and recovery trajectories. As discussed further, we
need to ascertain who is likely to respond to which kind of treatment and
why. In practical terms, we need a better knowledge base of the relevant risk
and protective factors for the development of disorder, the course of disor-
der, and response to treatment to improve our predictive capacity and tailor
our interventions accordingly. These predictors will, of course, need to take
into account pretrauma, peritrauma, and posttrauma variables in biological,
psychological, and social domains.
The Future of Traumatic Stress Treatments 521

Underlying Mechanisms

Great progress has been made in developing, and improving on, evidence-­
based treatments for PTSD and related conditions. This has resulted in four
core treatments for adults and three core treatments for children being
given the highest recommendation, and several others slightly lower recom-
mendations, in the ISTSS guidelines. Each of these has, or has the potential
for, variations in components and how it is delivered. For example, Chap-
ters 11–15 discuss variations to standard versions of the treatments in terms
of lengths of session, with and without writing components, massed versus
spaced versions, adaptations to service delivery context, and so on. Although
it is tempting to go down each of these pathways, conducting randomized
controlled trials (RCTs) to determine whether this or that particular nuance
results in a better outcome, this approach alone, even if more adaptive study
designs are adopted, will result in slow progress. It also risks the poten-
tial to fail to identify more fundamental principles that should be driving
our understanding of the field. To use an old quote, we risk “missing the
wood for the trees.” While not suggesting that the field should abandon
that approach—­it will always remain the core of good science and core to
expanding our evidence base—the time has also come to increase our focus
on the underlying mechanisms. This focus on underlying mechanisms needs
to consider both the processes underlying disorder development in addition
to the mechanisms of treatment effectiveness. Hence, this requires attention
to the interactions between biological, psychological, and social factors that
explain the development of, and recovery from, traumatic stress reactions.
One starting point in this search for core mechanisms involves identi-
fying common elements of successful treatments. Are our successful treat-
ments all doing the same thing, targeting the same underlying mechanisms?
Chapter 11 has attempted to extract the core components that are shared
by the treatments with the highest recommendations for adults: prolonged
exposure (PE), cognitive processing therapy (CPT), cognitive therapy for
PTSD (CT-PTSD), eye movement desensitization and reprocessing (EMDR)
therapy, and undifferentiated trauma-­focused cognitive-­behavioral therapy
(CBT). Three common elements are identified: addressing trauma-­related
cognitions, engaging with the traumatic memory, and addressing experi-
ential avoidance. Similarly, these same three common elements appear in
the child treatments with the highest recommendations (CBT-based trauma-­
focused therapy approaches targeting mainly the child, CBT-based trauma-­
focused therapy that is both child- and caregiver-­focused, and EMDR ther-
apy).
The authors in Chapter 11 speculated that information-­ processing
paradigms (along with changing the personal meaning of the trauma) may
go some way in explaining the mechanisms underlying those elements. We
will use the information-­processing paradigm to illustrate this discussion
about mechanisms of treatment action and their corresponding treatment
522 Application, Implementation, and Future Directions

interventions designed to directly or indirectly intervene on those mecha-

nisms. Those models broadly assume that the traumatic memory drives the
cognitive, physiological, behavioral, and affective symptoms associated with
PTSD and related conditions. For recovery to occur, that memory must be
modified. That is, the person first needs to activate and engage with the
traumatic memory to make it accessible for modification. Then the person
needs to engage with, process, and incorporate information that is inconsis-
tent with that contained in the memory. By doing so, links between trauma-­
related memories and responses in physiological, behavioral, and affective
domains are weakened. In addition, advances in theory and neuroscience
research suggest that original maladaptive trauma appraisals associated
with the memory are weakened by competing alternative cognitions (vs.
restructuring of them). It is assumed that, while PE, CPT, CT-PTSD, EMDR
therapy, and undifferentiated trauma-­focused CBT may use different treat-
ment means to manipulate these mechanisms, they are all achieving the
same ends by operating through these same underlying mechanisms.
Are there additional core elements of intervention that are shared by
most, if not all, successful treatments? Many approaches include, formally
or informally, at least some kind of attention to arousal reduction, anxiety
management, and broader emotion regulation. The research suggests these
approaches in isolation are not as efficacious in the treatment of PTSD—they
help the person to manage the symptoms but do not address the underlying
drivers. Nevertheless, as the authors of Chapter 19 note, a person’s ability to
reduce and control his or her reactivity to internal experience, to moderate
arousal, and to control attentional focus may be important agents of change.
If so, what is the mechanism? Perhaps they operate purely to facilitate the
underlying mechanism of change—­activation and modification of the trau-
matic memory or alternatively to make the underlying mechanisms high-
lighted more amenable to change by the common core elements previously
cited. Relatedly, it is also important to acknowledge the role, across all of
these treatments, of the nonspecific therapeutic alliance factors (therapeutic
relationship, empathy, support, shared goals) that have demonstrated effi-
cacy in their own right. Nevertheless, it is important to remain open to the
potential benefit of basic lifestyle interventions (e.g., aerobic exercise, diet,
sleep, hygiene, social engagement, enjoyable activities). There is a risk that,
in our desire to maximize our clinical and/or theoretical sophistication, we
may neglect these basic issues that have the potential to substantially improve
the person’s quality of life. Some clinicians may believe that addressing those
issues might be interpreted as minimizing or avoiding addressing the trau-
matic experience. It is important to remember, however, that although they
may not directly address the underlying traumatic stress mechanisms, the
resulting improved mental state will make that work much easier.
The discussion thus far has focused on psychological treatments because
they are supported by the strongest body of evidence. As noted in Chapter
16, however, pharmacological interventions also have an important role to
The Future of Traumatic Stress Treatments 523

play in the treatment of PTSD and related conditions. To the extent that
they are successful, do they operate through the same mechanisms? Is their
role primarily one of symptom management, reducing arousal and affective
distress to the point that the person is able to engage—­w ith or without a
therapist—­in the process of modifying traumatic memories? If so, perhaps
the reason for the slightly disappointing rate of success of pharmacotherapy
in PTSD is that these drugs are not directly targeting the core mechanisms
that underpin the disorder. The future, however, may be different. While
pharmacotherapy for PTSD to date has relied on drugs developed for other
reasons—­notably, antidepressants—­t here is increasing interest in drugs that
may selectively target the traumatic memory directly, as well as drugs that
may facilitate modification of the memories when administered during a
trauma-­focused therapy approach. Either way, the important message is to
improve our understanding of the mechanisms by which successful treat-
ments work so that they can be targeted directly.
A second potential body of evidence in the search for underlying mech-
anisms, beyond the commonalities of successful treatments, may lie in closer
examination of the natural course of traumatic stress reactions. We need
a better understanding of the mechanisms involved in long-term adverse
outcomes: Why do some people have problems, whereas others do not? Why
do some people show good recovery (without the need for professional assis-
tance), while others do not? The field has made good progress in discover-
ing risk indicators (i.e., characteristics of those subgroups in which PTSD is
more common, such as gender) and risk factors (i.e., for which there is clear
evidence of causal effect, such as exposure to further trauma). Some prog-
ress has been made in identifying potential protective factors, for example,
cognitive flexibility and social support (although negative support is a stron-
ger risk predictor). What the field has done less well to date is to use this
information about risk to generate hypotheses about the underlying mecha-
nisms that explain variations in human response to trauma. It is reasonable
to assume that these risk variables operate through similar mechanisms to
those discussed. That is, that there will be strong similarities between the
mechanisms that underpin healthy recovery in the absence of treatment
and those that underpin therapist-­assisted recovery. To use the information
processing paradigm discussed previously as an example, it may be that
those people who recover without treatment are able to access the traumatic
memory often enough and for long enough to allow it to be modified. This
mechanism of change is facilitated by a therapist in the case of treatment.
In those who do not receive treatment, it may be that risk and protective fac-
tors operate by facilitating or mitigating against activation and modification
of the trauma memory. A strong social support network, for example, may
make it easier to talk about what happened, whereas subsequent life stress-
ors may reduce the person’s capacity to address the original trauma.
In summary, while we continue RCT investigations of promising treat-
ments, we are likely to accelerate progress if we are able to identify more
524 Application, Implementation, and Future Directions

accurately the specific mechanisms that explain the development of, and
recovery from, disorder and target our treatments accordingly. In line with
the discussions in the previous section, this will require recognition of differ-
ent trauma responses—­trajectories and clinical presentations—­to determine
which mechanisms best explain each response type. Only by understanding
these different mechanisms can we effectively design treatment tailored to
the many different ways in which humans respond to trauma.

Improving Treatment Effectiveness

Moving on from mechanisms, the preceding chapters highlight the substan-

tial opportunities that exist to build on and improve existing treatments. As
discussed in Chapter 16, there is great potential to develop novel pharma-
cotherapies that target the specific neurobiological characteristics of PTSD,
thereby addressing the physiological and biological mechanisms that help to
explain the clinical picture. Beyond traditional pharmacotherapy, the ISTSS
guidelines for PTSD for the first time provide preliminary support for herbal
remedies based on traditional medicines. Other biological treatments such
as neurofeedback and transcranial magnetic stimulation also show promise
for further development. Chapter 18 discusses the considerable potential
that now exists and will continue to develop with advances in computing
and artificial intelligence for online and other technologically based treat-
ment approaches. Given the complex clinical picture of many PTSD presen-
tations, particularly in the context of the broad approach taken by DSM-
5, further research is required on the potential benefits of combining two
or more existing treatments. This may, for example, include acute-­acting
pharmacological and other augmentation agents to enhance specific com-
ponents of psychotherapy, such as 3,4-methylenedioxy-­methamphetamine
(MDMA) and similar trials discussed in Chapter 17. There has also been
important progress in research focused on bolstering effectiveness through
active engagement of supportive and significant others in treatment such as
couples- or family-­focused PTSD treatments. Chapter 19 also points the way
to emerging interventions in the alternative and complementary approaches
including meditation, yoga, and mindfulness-­based interventions, which,
although not designed for the treatment of PTSD specifically, are starting
to demonstrate impact on PTSD symptomatology. The inclusion of complex
PTSD as a recognized diagnostic category in ICD-11 will drive the explora-
tion of treatments that target the specific profile of that disorder. In light
of the high level of comorbidity highlighted in Chapter 22, transdiagnostic
approaches may be beneficial in addressing underlying shared core vulner-
abilities in PTSD and the common conditions.
While new and improved treatments for PTSD and related condi-
tions must be developed through a rigorous empirical approach, the field
needs to pay greater attention to their applicability in practical real-world
The Future of Traumatic Stress Treatments 525

applications. That is, can they be delivered effectively by clinicians across

the community in their mental health clinics and consulting rooms? Fur-
thermore, can these treatments be delivered beyond these mental health
settings to include, for example, primary care settings and, for children and
adolescents, potentially in school settings? We need to consider who will be
engaged in the treatment process and how. With young children, for exam-
ple, to what extent should we just work with parents rather than also actively
involving the child in treatment? With adults, what difference does partner
involvement make, and how and when should a partner be involved? We
need to continue to expand our treatment trials with different populations
in different settings, outside of specialized university clinics with first-class
training and supervision. To enhance this broader applicability, researchers
should aim to include end-user input and validation throughout the devel-
opment process. We need to further promote clinical evaluation as part of
routine care, with better collection of these data to inform development
of future interventions applicable to real-world settings beyond traditional
RCT designs. In this context, research also needs to explore how much a
given treatment can be simplified or “degraded” and still maintain its effi-
cacy. With which populations and clinical presentations will the “degraded”
versions of treatment be sufficient, and who will continue to require the full
protocol to achieve the desired results?
Beyond simply developing new or improved treatments, a major chal-
lenge for the field is developing our capacity to match the timing, type,
and intensity of treatment to specific risk profiles and clinical presentations.
This work will need to build on both a better understanding of the range of
trajectories and symptom profiles following trauma exposure, and a greater
focus on the mechanisms. Although the concept of personalized medicine
is not new, it has yet to be systematically adopted in our approach to trauma
treatment. Any suggestion that “one size fits all” when it comes to PTSD
and related conditions is not borne out by the relatively modest treatment
outcomes for some people with PTSD. The transdiagnostic approaches to
treatment that focus more on dimensions or themes, rather than specific
diagnoses, make it easier to design individual treatments to match specific
clinical profiles. This concept of designing treatment to the specific needs
of the patient applies not only to psychological constructs but also to phar-
macological and other biological factors. A more sophisticated knowledge of
genetic influences on trauma recovery, for example, may help guide decision
making about which drugs (or psychological therapies) might have the best
chance of success with different patients. In short, we need to do better at
matching specific treatments (alone or in combination), as well as their dose,
timing, and mode of delivery, to different subgroups of the affected popula-
tion and different subtypes of clinical presentation.
Improving treatment may also involve paying greater attention to the
desired outcomes. RCTs traditionally, and with good reason, focus primarily
on symptom reduction with the main focus on PTSD. In real-world settings,
526 Application, Implementation, and Future Directions

however, the person’s needs and goals are often much broader and, indeed,
PTSD symptoms may not be the dominant concern. Being cognizant of that,
it is important that the field stay open to a wide range of potential outcomes
and that we strive to measure recovery in a more holistic way. This should,
of course, critically include symptom reduction across PTSD and any comor-
bid conditions, but ought to also include attention to social relationships,
occupational functioning (in the broadest sense), and quality of life. Symp-
tom reduction without improvements in those other areas is likely to be of
limited benefit to our patients. Equally, improvements in those other areas
may go some way in reducing the severity of core symptoms or, at least, make
treatment or self-­management of those symptoms easier.
In this context, it is important to differentiate between those inter-
ventions that are designed primarily to reduce core symptoms, hopefully
by addressing the underlying mechanisms, and those that are designed to
improve quality of life and assist the client to manage his or her condition.
Recent years have seen a substantial growth in interest around broader
activities, approaches, and interventions such as a range of pet therapies
(particularly stratifications in the sophistication of canine therapies) and
outdoor physical challenges. These interventions clearly have the potential
to be beneficial for some people with the disorder, enhancing broader qual-
ity of life and well-being in different ways. Rather than ruling them out on
the grounds of lack of data in reliably reducing PTSD symptoms, the field
needs to engage with these approaches by rigorously defining what they
are designed to achieve. There is scope for some of them to become useful
adjuncts to mainstream PTSD treatments in the search for more holistic
outcomes. It also may be that over time these approaches and interventions
demonstrate direct impact on PTSD symptoms. On a related theme, there
is scope to improve our differentiation between active treatment and “main-
tenance.” Although it is often suggested that the latter is superfluous and
does not require a mental health professional, many clinicians would argue
that a small proportion of their people with PTSD do require regular, albeit
infrequent, contact to minimize the chance of relapse. This is a legitimate
area for study: Who needs it and what should it comprise?
A final consideration in striving to improve our treatments is a better
analysis of who does not respond to treatment and why. Several of the pre-
ceding chapters attempt to address this issue, with Chapter 13 suggesting
that, at least for CPT, two common themes that emerge are lack of thera-
pist fidelity to the protocol and problems with homework compliance. The
first is potentially addressed through better training and more consistent
supervision—­not always easy for practitioners to arrange in routine clinical
practice. The second, difficulties with compliance, is by no means unique
to trauma treatments and has been the focus of considerable interest in the
behavioral field. Here, we also need to consider the role of measurement-­
based care, where results and outcomes are actually used collaboratively and
clinically with the patient. It may not only be helpful in guiding personalized
The Future of Traumatic Stress Treatments 527

approaches to treatment but also a very compelling process to aid practitio-

ners in remaining “on course.” It is a complex issue, and we need to under-
stand the multiple potential contributing factors if we are to address it effec-
tively. Although it may be tempting at times for some clinicians, it is not
sufficient to “blame” the client for not working hard enough or not being
committed to treatment. Rather, the subtle contingencies that are operating
need to be examined. We need to acknowledge that even if delivered with
perfect fidelity and full patient compliance to protocol and homework, it
remains unlikely that everyone with PTSD would be “cured” with the cur-
rent treatments. More broadly, the field needs to gain a better understand-
ing of treatment moderators—­t hose factors that facilitate or mitigate against
a good treatment outcome. One simple example provided in Chapter 13 is
patient preference: clients who are actively engaged in treatment planning
and who have a say in which treatment they undergo are likely to respond
better. This highlights the importance of taking a collaborative approach in
the early stages of treatment planning. Ultimately, we seek to progress to a
future where we are able to offer people with PTSD the choice of equally
effective treatments that involve different techniques/paradigms that sit
within a personalized medicine framework.

Challenges in Implementing Best Practice

Following from the discussion above regarding the importance of ensur-

ing that our recommended treatments are applicable in real-world settings,
continued efforts need to be devoted to implementation issues. These chal-
lenges are discussed in detail in Chapter 24: How best can we disseminate
those treatments that have demonstrable effectiveness? How do we train
and support clinicians as they work to implement those treatments? It is
clear that our approach to this complex challenge needs to be flexible and
multifaceted to address the unique and diverse challenges that each treat-
ment setting faces when endeavoring to deliver evidence-­based treatments to
survivors of trauma. Several barriers to care have been identified including
patient-­based (e.g., stigma, personal beliefs about mental health treatment,
readiness to change), clinician-­based (e.g., poor training, low confidence,
lack of understanding about effective treatments, lack of commitment to
evidence-­based care), and structural/organizational barriers (e.g., accessibil-
ity, complex service systems to negotiate, service gaps). Effective implemen-
tation of best-­practice treatments needs to take into account, and address,
these multiple barriers in a coherent and systematic way rather than focus-
ing on only one or two.
Resource allocation is often a challenge for mental health providers.
Although it is important to advocate for greater resources in responding to
the mental health effects of trauma, the reality is that many clinicians will
be working in underresourced areas. It is incumbent on the field to explore
528 Application, Implementation, and Future Directions

delivery options that make optimal use of limited resources while not com-
promising treatment efficacy. Considerations may include, for example,
ensuring that interventions following trauma are delivered at the optimum
time, neither too early nor too late to achieve the best outcomes in the most
efficient manner. Indeed, determining this represents a research question
in its own right. Dosing is important: How much treatment is required and
at what frequency? Are “therapy breaks” useful? Similarly, with the ISTSS
guidelines reporting increasing evidence from several recommended inter-
ventions suggesting that massed treatment (e.g., several hours daily over 2
weeks) may be as effective as more traditional therapy models, it is worth
considering which might be the most efficient in any given setting. For cli-
ents in rural and remote areas, as well as those who find it hard to get to
a clinic for other reasons, delivery via video technology holds considerable
promise and may be a cheaper but equally effective alternative in some cases.
The model proposed for CPT in Chapter 13 that uses a combination of self-
study modules with therapist sessions appears to reduce the practitioner
resources required without loss of treatment efficacy. All of these efficiency
measures, however, must be supported with appropriate research evidence.
Although many are, some of the suggestions still require empirical support.
This discussion has been oriented primarily toward mental health services
in high-­income countries. While increasing attention has been devoted to
the delivery of evidence-­based treatments for trauma survivors in low- and
middle-­income countries, the challenges in those settings are, of course, sub-
stantially greater.
It is clear from Chapter 25 that providing evidence-­based treatments
for PTSD and related conditions is cost-­effective. This is vital evidence to
bring to the attention of governments and other purchasers of services (such
as third-party insurers) as well as to senior management in service delivery
organizations. Although it may require greater commitment from consum-
ers, clinicians, health agencies, and purchasers, the long-term benefits in
terms of both cost savings and quality of life are now clearly demonstrable.
In implementing evidence-­based treatments for PTSD in health care settings
across the community, however, other factors in addition to clinical and cost-­
effectiveness require consideration. Ethical issues, equity, and legislative
aspects should be also considered when making decisions on the allocation
of health care resources.

Conclusions: Future Research Directions

The previous sections have proposed many areas for future research. In
short, we need to better understand the nature and course of traumatic
stress reactions—­t he different trajectories and clinical presentations—­as well
as improving our identification and prediction of these various responses
to traumatic experiences. We need to increase our research focus on the
The Future of Traumatic Stress Treatments 529

mechanisms that underlie recovery from trauma exposure, both within and
beyond the therapeutic context. We need to continue our efforts to develop
new treatments and improve our existing interventions, while also ensur-
ing that they are applicable to real-world settings and that they pay atten-
tion to a broad range of therapeutic outcomes. Finally, we need to place a
greater emphasis on empirically supported strategies for dissemination and
implementation, while recognizing the constraints inherent in many mental
health service settings.
Many of these research questions can only be addressed in a limited
fashion with modest, single-­site studies. While there will always be a place
for that research, the time has come to take traumatic stress research to the
next level. We now have the computing capacity to deal with extremely large
bodies of data. By combining multiple data sets from different sites and
using newly developed sophisticated data analytic techniques, we have the
potential to answer many of the complex questions raised in this discussion.
The challenge now is to find ways to engage the international research com-
munity in collaborative efforts to solve these issues confronting the field.
This will require not only commitment and funding, but also the develop-
ment of appropriate structures within which these research collaborations
can flourish.
The future for the field of traumatic stress has never looked more prom-
ising. Although there is much work still to do, the 2018 ISTSS guidelines and
the preceding chapters attest to the enormous gains that have been made
over the last 20 years. We now have a range of effective treatments for PTSD
and related conditions that are constantly evolving to improve outcomes and
meet the various challenges. A host of opportunities now present themselves
to clinicians, researchers, and policymakers, all of whom share the same
goal of improving outcomes for people affected by trauma.
Author Index

Aakvaag, H. F., 32 Amen, D. G., 236

Aarons, G. A., 479 Ament, A. J., 495
Aas, E., 504 American Psychiatric Association, 5, 10, 14, 15, 30, 33,
Abdallah, G., 401 36, 49, 50, 60, 83, 221, 237, 426
Aboharb, F., 461 American Psychological Association, 8, 188, 287, 306,
Abrahams, N., 15 310, 369, 469
Abramovitz, S. M., 248 Amoroso, T., 275
Abramowitz, S. A., 59 Amrhein, P. C., 224
Abrams, J., 238 Anderson, E., 197
Acarturk, C., 242, 243, 246 Anderson, V., 83
Acharya, A., 495 Andersson, G., 314, 317, 318, 322, 334
Achim, A. M., 427 Andrew, M., 260, 334, 420
Acierno, R., 197 Andrews, B., 19, 50
Acker, K., 428 Andrews, G., 510
Adams, G. A., 54 Angkaw, A. C., 424
Adams, Z. W., 31, 69, 424 Angold, A., 30, 433
Adamson, G., 428 Anh le, V., 343
Adebajo, S., 58 Antonsen, S., 16, 21, 22
Aderka, I. M., 200 Arata, C. M., 38
Ades, A. E., 509
Arch, J. J., 462
Adler-Tapia, R., 244
Arendt, M., 427
Afana, A. H., 58
Arensdorf, A. M., 454
Afifi, T. O., 33
Armfield, F., 123
Ahles, E., 452
Armour, C., 118, 120, 428
Ahmadi, N., 352, 492
Armstrong, D. W., III, 60
Ahn, C., 216
Ahmed, R., 427 Armstrong, S., 245
Ahrens, J., 215 Arnberg, F., 319
Air, T. M., 492 Artigas, L., 124, 126, 246
Aisenberg, E., 401 Artz, C., 216
Alarcon, R. D., 315 Ashwick, R., 314
Albano, A. M., 82 Asmundson, G. J. G., 22, 352, 431, 432, 433, 438
Alcazar, M. A., 304 Asnaani, A., 76, 80, 82, 179
Alda, M., 462 Astin, M. C., 193, 214, 241
Aldahadha, B., 242 Asukai, N., 193, 200
Alderfer, M. A., 148 A-Tjak, J. G., 170
Alisic, E., 30, 31, 32, 35, 40, 69, 70, 83 Atwoli, L., 17
Allen, D. N., 55 Auerbach, A., 451
Allen, N. B., 433 Auslander, B. A., 36
Allon, M., 453 Austin, S. B., 15
Almlöv, J., 334 Australian Centre for Posttraumatic Mental Health,
Alonso, J., 492 91, 241
Alterman, A. I., 425 Australian Psychological Society, 478
Alvarez, J., 425 Australian Red Cross & Australian Psychological
Amaya-Jackson, L., 321, 395, 400, 475 Society, 122–123
Ameenat, A., 142 Axsom, D., 17

530
Author Index 531

Back, S. E., 181, 200, 417, 422, 423, 424, 425, 426 Berlin, H. A., 282
Baddeley, A., 235 Berliner, L., 3, 50, 69, 76, 80, 106, 109, 183, 366, 385,
Baek, J., 236 387, 390, 475, 480, 518
Bailey, B. N., 38 Bernal, G., 452
Bailey, G. W., 218 Bernardy, N., 182
Bailey, K., 317 Bernstein, A., 421
Baker, A., 278 Best, C. L., 23
Bakker, A., 36, 315, 319 Best, S. R., 19
Balang, R. V., 31 Betancourt, T. S., 58
Baldwin, C. M., 344 Bethell, A., 317
Ball, T. M., 462 Bhugra, D., 58
Baltussen, R. M., 495 Bicanic, I. A., 40
Ban, J., 38 Bikman, M., 351
Banks, K., 371 Billings, J., 262
Bannon, W. M., 481 Bishop, S. L., 326
Banta, J. E., 493 Bisson, J. I., 3, 9, 15, 49, 51, 58, 90, 106, 109, 122, 123,
Barak, A., 317 125, 128, 129, 137, 138, 139, 142, 183, 192, 221, 260,
Barakat, L. P., 149 272, 278, 287, 317, 319, 334, 369, 385, 418, 419, 420,
Barbui, C., 138 421, 518
Barlow, D. H., 21, 420, 421, 434, 435, 436, 452, 469 Black, A., 394, 453
Barnes, T. R. E., 278 Blain, L. M., 215
Barnett, M., 472, 473 Blanchard, E. B., 51, 193
Barron, I. G., 401 Blanco, C., 21, 422
Barth, R. P., 39 Blase, K. A., 470
Bashti, S., 246 Blaustein, M., 428
Bass, J. K., 216, 219, 452, 474 Blevins, C. A., 59, 219, 319, 481
Bassett, A. S., 427 Blier, P., 281
Basten, C., 128 Blount, T. B., 193, 201
Bates, G., 22 Boden, M. T., 425
Bates, P. B., 178 Boer, F., 399
Battaglia, J., 322 Bohnert, K. M., 4
Baumann, B. L., 470 Bohus, M., 374, 375
Baweja, S., 152 Bolte, T. A., 217
Bearman, S. K., 436 Bolton, P., 216, 435, 438, 452, 453, 474
Bears, M., 238 Bommaritto, M., 55
Beatty, L., 316, 326 Bonanno, G. A., 34, 118, 119, 120
Bech, P., 300 Bonato, S., 438
Beck, A. T., 210, 387 Bond, G. R., 478
Becker, C. B., 197, 198 Bonilla-Escobar, F. J., 435
Becker, D. F., 119 Bonn-Miller, M. O., 425
Becker, L. A., 237, 243 Bonomo, Y., 433
Becker, M. A., 58 Boos, A., 268
Beckham, J. C., 492 Borah, E. V., 469, 474, 476, 477, 482
Bedard-Gilligan, M., 50, 216, 299 Borba, C. P., 452
Beebe, K. L., 277 Borges, G., 22
Behnammoghadam, M., 246 Borghini, A., 122
Behnammoghadam, Z., 246 Bormann, J. E., 345, 346, 348, 353
Beidas, R. S., 470, 471, 472, 473, 477, 480 Borntrager, C. F., 455
Beiser, M., 58 Borsboom, D., 417
Bell, J. R., 344 Boscarino, J. A., 352
Bellehsen, M., 347 Bosco, M. A., 432, 433
Belli, G. M., 179 Bosmajian, C. P., 316
Bellivier, F., 427 Bosquet Enlow, M., 76, 79
Belsher, B. E., 182 Bossarte, R. M., 461
Bengel, J., 61 Bossini, L., 236
Benight, C. C., 316, 326 Botella, C., 323
Benjamin, A., 399 Boterhoven de Haan, K. L., 237, 243, 244, 248
Benjet, C., 14, 15, 16, 17 Boukezzi, S., 236
Bennett, A. J., 324 Bouso, J. C., 304
Bennett, I. M., 457 Boustani, M. M., 434
Bennett, K., 324, 333 Bouton, M. E., 142
Benton, A. H., 475 Bovin, M. J., 438
Berbiche, D., 492 Bowen, E., 437
Berger, L. M., 37 Bower, P., 332
Berger, R., 152, 159, 401 Brackbill, R. M., 417
Berger, T., 334 Bradley, M. M., 235
Bergh Johannesson, K., 319 Brady, K. T., 200, 321, 423, 424, 425
Berglund, P., 19, 21 Brand, J., 327
Bergstraesser, E., 156 Brazier, J., 494
Beristianos, M. H., 22 Bremner, J. D., 347
Berkowitz, A., 316 Brennan, K., 388
Berkowitz, S., 153, 156, 159, 161 Brennan, M. B., 189
532 Author Index

Brennenstuhl, M. J., 431, 432 Cancienne, J., 428

Brent, D., 36 Capaldi, S., 76, 80, 82, 200, 390
Brent, D. A., 36 Capezzani, L., 241, 242
Breslau, N., 19, 321 Cardenas, J., 400
Brewer, S. K., 400 Carlbring, P., 129, 322, 334
Brewerton, T., 321 Carletto, S., 241, 242
Brewerton, T. D., 309 Carliner, H., 433
Brewin, C. R., 15, 19, 49, 50, 51, 52, 53, 55, 58, 60, 61, Carlson, E. B., 57
210, 260, 369, 386, 387 Carlson, J. G., 241, 242, 243, 245, 246
Bridges, S., 18 Carlson, J. S., 39
Briere, J., 79 Carlsson, J., 300
Briggs, A., 496 Carr, C., 351
Briggs, E. C., 434 Carr, C. P., 427
Bristow, R. G., 461 Carr, V. J., 427
Broekman, T. G., 301 Carroll, K. M., 200
Brogan, M., 454 Carter, J. J., 349
Brom, D., 122, 351 Carter, R., 495, 496
Bromet, E., 20, 21, 417, 492 Casey, B. J., 462
Brooks, A. J., 344 Caspi, A., 433
Brown, E. B., 277 Castle, D. J., 427
Brown, F. L., 155 Catani, C., 35, 59, 153, 156
Brown, L. A., 179 Cattane, N., 429
Brown, P. J., 221 Cattaneo, A., 429
Brown, S., 437 Cementon, E., 433
Brown, T. A., 21, 417, 421 Center for Deployment Psychology, 477, 480, 481, 482
Browne, K. C., 425 Cernvall, M., 129, 319
Browne, K. D., 39 Chambless, D. L., 260, 457
Brownridge, D. A., 33 Chan, A. O., 492
Bruce, S. E., 218 Chan, D., 493
Brunet, A., 124, 294, 306 Chan, S. F., 37
Bruns, E. J., 474, 478, 482 Chaney, E. F., 321, 493
Bryan, C. J., 219 Chang, R., 425
Bryant, B., 386 Chard, K. M., 6, 172, 210, 211, 215, 216, 217, 218, 220,
Bryant, R. A., 4, 19, 22, 50, 51, 54, 55, 57, 117, 118, 119, 221, 222, 317, 420, 473
120, 125, 128, 129, 130, 137, 180, 193, 241, 269, 315, Charney, D., 21
388, 425, 452 Charney, D. S., 17, 21, 461
Brzustowicz, L. M., 427 Charney, M. E., 472, 473
Bucciarelli, A., 118 Charquero-Ballester, M., 261
Buckley, P. F., 427 Chaudhry, S., 356
Buckley, S., 238 Cheadle, A. D., 321, 493
Buckley, T., 182 Chemtob, C. M., 241, 246
Buckley, T. C., 51 Chen, J. A., 474, 479
Bugg, A., 127, 129 Chen, K., 477
Buhmann, C. B. O., 289, 300 Chen, Y. R., 242
Bui, E., 83 Cheng, C., 438
Bunnell, B. E., 201 Cheng, T. C., 496
Bürger, C., 317 Chhean, D., 422
Burgers, J. S., 418 Cho, V. W., 128
Burton, M., 287 Choi, J., 236
Burton, M. S., 199 Chorpita, B. F., 434, 435, 454, 455, 469
Bush, N. E., 316 Chow, E. W., 427
Bustamante, V., 142 Chowdhary, N., 21, 474
Butcher, F., 16 Chrestman, K., 188, 317, 350, 397, 420
Butler, L., 161 Christensen, H., 314, 316, 322, 323, 324, 335
Butollo, W., 216 Christman, S. D., 238
Buxton, M., 496 Christodoulides, J., 55
Byers, A. L., 22 Christofferson, J., 148
Byford, S., 495 Christopher, N. C., 35
Bystritsky, A., 354 Churchill, E., 60
Churchill, R., 122
Cahill, S. P., 178, 189, 192, 200 Ciesielskil, B. G., 22
Caldwell, C. D., 277 Cigrang, J. A., 193, 201, 202
Caldwell, D. M., 509 Cimo, A., 438
Caldwell, T. M., 322 Cipriani, A., 281, 509
Calhoun, P. S., 492 Cisler, J., 70
Callahan, J. L., 184 Cisler, J. M., 37, 321
Callender, K., 188 Ciulla, R. P., 316
Cameron, M., 399 Clancy, C., 418
Campbell, A., 170 Clark, D. M., 6, 55, 173, 210, 255, 256, 257, 258, 259,
Campbell, L. A., 417 260, 261, 262, 269, 386, 387, 395, 469, 475, 476
Canadian Agency for Drugs and Technologies in Clark, M. E., 432
Health, 493–494, 496 Clarke, S. B., 217, 430
Canadian Psychological Association, 476, 478 Claxton, K., 493, 496
Author Index 533

Cloitre, M., 15, 49, 52, 57, 58, 61, 106, 109, 152, 170, Danese, A., 50, 69, 366, 390
180, 275, 321, 365, 368, 369, 374, 375, 390, 402, Dang, S. T., 128, 180
403, 451, 459 Daniella, D., 142
Clum, G. A., 193 Dansky, B. S., 23, 200, 421
Cobham, V. E., 40 Danzi, B. A., 37
Cohen, B., 22, 347 Darnell, D., 434
Cohen, G. H., 498, 509 David, M.-C., 323
Cohen, J., 36, 80, 241, 385, 433 Davidson, J., 297
Cohen, J. A., 33, 35, 37, 40, 387, 390, 394, 395, 401, Davidson, J. R. T., 60
405, 473 Davidson, P., 388
Cohen, L., 180 Davidson, T. R., 51
Cohen, L. R., 374, 402, 403 Davis, A. C., 470
Cohen, Z., 170, 390, 451 Davis, G. C., 19, 321
Cohen, Z. D., 456, 457, 458, 459, 461 Davis, J., 421
Coid, J., 16 Davis, L. L., 347
Collins, F. S., 334 Davis, M., 301
Collins, L. M., 455 Davis, M. T., 59, 219, 319, 481
Cone, J. E., 417 Daviss, W., 40
Connell, A. M., 199 Day, A. M., 423
Connell, C. M., 37, 38, 76, 79 Day, N. L., 38
Conrod, P. J., 21 Day, S. J., 55
Conroy, R., 30, 83 de Arellano, M. A., 401–402
Cook, J. M., 182, 477, 480 de Bont, P. A. J. M., 60
Coolhart, D., 221 De Buck, E., 123
Coons, M. J., 22, 431 de Corral, P., 128
Cooper, A. A., 188, 287 De Genna, N. M., 38
Cooper, N. A., 193 de Haan, A., 81, 388
Cooper, R., 260, 334, 420 de Jong, J. T., 59
Copeland, W. E., 30, 32, 33 de Jongh, A., 241, 242
Coppens, E., 431, 432 De Jongh, A., 374, 404
Cordova, M. J., 124 de Kleine, R. A., 291, 301, 303
Corliss, H. L., 15 de Koninck, J., 55
Cornelius, M. D., 38 de Roos, C., 246, 399
Corrigan, P. W., 322 de Vries, G.-J., 315
Corry, J., 510 De Young, A. C., 40
Cosgrove, K., 376 Dear, K. B., 322
Costa, B., 127 Deblinger, E., 387, 390, 394, 473, 475
Costello, E. J., 31, 433 Decker, M. R., 32
Cougle, J. R., 420, 421 Dedert, E. A., 492
Courtney, M., 69 Deisenhofer, A. K., 461
Courtney, M. E., 32 Dekker, W., 278
Courtois, C. A., 366, 367, 374, 380 Dekkers, A. M. M., 61
Coventry, P., 369, 370 Delahanty, D., 141
Cox, B. J., 22 Delahanty, D. L., 22, 35, 39, 149, 321
Cox, C., 35, 155, 160, 161 Demyttenaere, K., 32
Cramer, A. O. J., 417 Department of Defense, 188
Crane-Godreau, M. A., 350 Department of Defense Clinical Practice Working
Craske, M. G., 420, 434 Group, 8
Crawford, J. N., 348 Department of Veterans Affairs, 8, 188
Creamer, M., 22, 54, 55, 120 deRoon-Cassini, T. A., 119, 120
Creech, S. K., 438 DeRosa, R., 402
Creed, T. A., 473 DeRubeis, R. J., 456, 457, 458, 459, 460, 461
Crestani, A. P., 235 Des Groseilliers, I. B., 124
Cribbie, R. A., 389 Desai, R., 354, 422
Crits-Christoph, P., 451 Desmarais, S. L., 427
Cross, G., 474, 478 Devilly, G. J., 241
Cross, W. F., 471 Dewa, C. S., 438
Crozier, J. C., 39 Diab, M., 34
Cueva, J. E., 405 Dibaj, I., 431, 433
Cuijpers, P., 138, 235, 238, 314, 317, 318, 334, 399 Dickstein, B. D., 119, 218, 220
Curran, D., 388 Diehle, J., 399
Cusack, K. J., 188, 287, 428 Dieltjens, T., 123
Czajkowski, N. O., 388 Dierkhising, C., 69
Difede, J., 287, 291, 301, 302, 303, 315
D’Abrew, N., 70 Dillen, L., 36
Dagnall, N., 238 Dimeff, L. A., 470, 471, 472
Daleiden, E. L., 435, 454 Dimsdale, J., 140
Dalgarno, B., 471 Dirkzwager, A. J., 39
Dalgleish, T., 35, 40, 386 Dixon, L., 452
Dali, G., 127 Dixon, L. E., 452
Damschroder, L. J., 479 Doblin, R., 304
Dancu, C. V., 60 Doctor, J. N., 494, 499
D’Andrea, W., 33 Dodd, J. C., 320
534 Author Index

Doebbeling, B. N., 21, 55 Ertl, V., 59

Domenech Rodríguez, M. M., 452 Etain, B., 427
Domin Chan, P., 321 Etkin, A., 461
Domino, J. L., 59, 219, 319, 481 Evans, D. B., 495
Dong, M., 32 Evans, K., 314
Donker, T., 317, 324, 335 Evans-Campbell, T., 59
Donkervoet, C., 454 Evers, S. M., 495
Donlon, K. A., 35
Dorn, T., 39 Fahlke, C., 38
Doron-LaMarca, S., 419 Fairall, J. M., 316
Dorr, F., 61 Fairbank, J. A., 54
Dorsey, S., 434, 469, 471, 475, 479, 480, 481 Fairburn, C. G., 323
Doss, A. J., 469 Falsetti, S., 421, 422
Dow, B. L., 61 Falsetti, S. A., 421
Drake, R. E., 478 Fama, J. M., 420
Drevets, W. C., 461 Farahnak, L. R., 479
Drummnod, M. F., 493, 494, 495 Farchione, T. J., 435
Drummond, P. D., 239, 241 Farfel, M. R., 417
Druss, B. G., 322 Farmer, C. C., 184, 217, 225
Dube, S. R., 433 Farre, M., 304
Dubois, R. W., 496 Farrington, A., 83
DuCette, J. P., 424 Faupel, A., 83
Duffy, M., 259, 260 Fear, N., 18
Duke, L. A., 55 Feeny, N. C., 125, 184, 188, 199, 226, 287, 299, 309,
Duncan, L. E., 21, 283, 427 419, 430, 494, 499
Dunn, N. J., 498 Fegert, J., 402
Dvorak, R. D., 423 Fein, J. A., 36
Dyb, G., 32, 38, 39, 147, 433 Feingold, Z. R., 218
Dyer, A., 375 Feldner, M. T., 420
Dyer, K. F., 388 Fennell, M., 6, 259, 395
Dyregrov, A., 79 Fenwick, E., 496
Dzus, E., 318 Ferenschak, M. P., 188
Ferguson, S., 376
Eaton, J., 21 Fernando, S., 32
Eaton, W. W., 332, 333 Ferry, F. R., 493
Ebert, L., 475 Fetzner, M. G., 352
Echeburúa, E., 128 Feuer, C. A., 193, 214
Eckenrode, J., 39 Field, A., 70
Edmond, T., 242 Field, A. P., 35
Edmunds, J. M., 471, 472, 480 Field, N. P., 452
Edney, L. C., 496 Fielding, K. S., 481
Edwards-Stewart, A., 197 Figley, C. R., 237, 245
Eftekhari, A., 469, 473 Fink, D. S., 119
Egede, L. E., 427 Finkelhor, D., 31, 32, 38, 69, 72, 73
Ehlers, A., 6, 55, 125, 128, 129, 169, 173, 183, 210, 255, Finley, E. P., 474, 476, 482
256, 257, 258, 259, 260, 261, 262, 268, 269, 307, 317, Finney, J. W., 221
386, 387, 388, 395 Fins, A. I., 142
Ehrenreich-May, J., 436 First, M. B., 51, 55
Ehrhart, M. G., 479 Fishbain, A., 431, 432
Ehring, T., 60, 424, 425 Fisher, P. A., 39
Eibner, C., 510 Fitch, K. E., 420
Ein-Dor, T., 419 Fitzpatrick, S., 227
Eisenbruch, M., 58 Fitzpatrick, S. L., 36
Ekselius, L., 322 Fixsen, D. L., 470
Ekstroem, M., 300 Fjermestad, K., 70
El Khoury-Malhame, M., 248 Fjermestad, K. W., 388
Elbert, T., 452 Flannery, D. J., 16
Elhai, J., 182 Flory, J. D., 21, 419
Elklit, A., 31, 118, 300 Foa, E. B., 4, 6, 60, 76, 80, 81, 82, 125, 128, 129, 178,
El-Leithy, S., 262 179, 181, 188, 189, 190, 191, 193, 196, 198, 199, 200,
Elmore Borbon, D. L., 117 201, 202, 210, 214, 221, 262, 264, 269, 317, 350, 387,
Elofsson, U. O. E., 235 388, 390, 393, 397, 398, 420, 422, 425, 430
Elsesser, K., 128 Follette, V. M., 192, 371
Elwood, L., 215 Fontaine, J. R., 36
Emerson, D., 356 Fonzo, G. A., 193
Emery, G., 210 Forbes, D., 3, 22, 106, 109, 117, 137, 169, 180, 181, 183,
Emmelkamp, P. M., 60, 125, 126, 182, 247, 424, 425 184, 216, 241, 315, 385, 417, 419, 436, 518
Engel, C. C., 60, 327, 349 Ford, H. L., 193
Ennis, N., 315 Ford, J. D., 33, 59, 152, 180, 365, 366, 367, 372, 374,
Epskamp, S., 417 376, 380, 402, 425
Epstein, R. S., 322 Forneris, C. A., 51
Erickson, T., 318 Forrester, A., 475
Erkanli, A., 433 Fortney, J. C., 481
Author Index 535

Fournier, C., 348 Goldstein, R. B., 19, 20, 422

Fox, J. H., 123 Goldstrom, E., 72
Fox-Galalis, A. B., 218 Golier, J. A., 430
Frandsen, L., 31 Golshan, S., 345, 346
Fredman, S. J., 438 Gomez, A., 245
Freed, M. C., 60, 494 Gomez-Jarabo, G., 304
Freedy, J. R., 60 Gone, J. P., 59
Freud, B., 241 Gonzalez, A., 400
Freyth, C., 128, 129 Gooding, P. A., 419
Friedman, M. J., 50 Goodman, L. A., 428
Friedman, R. M., 470 Goodson, J. T., 193
Frijling, J. L., 131 Gootzeit, J., 54, 55
Frisman, L., 425 Gore, K. L., 60
Frost, R., 57 Gospodarevskaya, E., 494, 504
Frueh, B. C., 182, 427, 428, 429 Gottlieb, J. D., 426
Fuchkan, N., 61 Gouweloos-Trines, J., 61
Fulcher, L., 224 Gowen, L. K., 32, 69
Fuller, A. K., 400 Graap, K., 315
Funderburk, J. S., 221 Gradus, J. L., 13, 16, 21, 22, 24, 193, 214, 218, 221
Grady, R. H., 481
Gabbe, B. J., 127 Graf, A., 156
Gäbler, I., 54 Graham, J. R., 478
Gahm, G., 315 Graham-Bermann, S. A., 39
Gaines, J., 32 Grant, B. F., 19, 422
Galanek, J. D., 16 Grauerholz, L., 16
Galatzer-Levy, I. R., 50, 51, 119, 120 Gray, A., 496
Galea, S., 51, 118, 119 Gray, C., 70
Gallinati, J. L., 432 Gray, S., 477
Gallop, R., 429 Green, C. E., 425
Galovski, T. E., 184, 210, 215, 217, 218, 226, 317, 420, Green, S., 91, 140, 276
438 Greenley, D., 323
Ganoczy, D., 4 Greenwald, R., 241
Gao, J., 431 Grey, N., 258, 260, 267
Gard, T., 345 Griffin, M. G., 216, 218
Garner, A. S., 72 Griffiths, K. M., 314, 322, 324
Garner, B., 275 Grills, A. E., 320
Garvert, D. W., 57, 182 Grills-Taquechel, A. E., 17, 433
Garvey, K. J., 238 Grisham, J. R., 417
Gary, D., 433 Grob, C. S., 309
Gavriel, H., 241 Groessl, E. J., 350
Gawrysiak, M. J., 193 Gros, D. F., 60, 197, 425
Gega, L., 318 Gross, J. J., 425
Gelkopf, M., 152, 351, 401 Gross, P., 478
Gellatly, R., 434 Grossman, P., 348
German, R. E., 472, 473 Grove, R., 18
Gersons, B. P., 34, 60, 130, 241 Grubaugh, A. L., 182, 427, 428, 429
Gersons, B. R., 315 Gudiño, O., 402, 404
Ghazali, S. R., 31 Gudiño, O. G., 403, 404
Giannatsi, M., 509 Gullone, A., 376
Gibbs, L., 39 Gunaratnam, S., 31, 35
Gidron, Y., 122 Gunderson, J. G., 429
Gielen, N., 422, 424 Guo, T., 278
Gilbert, P., 371 Gureje, O., 343
Gilboa-Schechtman, E., 200, 398 Gurwitch, R., 123
Gilbody, S., 332, 333 Gustavsson, A., 493
Gilles, D., 70 Guterman, N. B., 399
Gillespie, K., 259, 260 Gutermann, J., 70, 390
Gillette, C. S., 241 Guthrie, D., 395
Gillihan, S. J., 4, 188, 200, 269, 425 Guthrie, R., 128
Gilpin, N. W., 423 Guthrie, R. M., 180
Ginzburg, K., 419 Gutner, C. A., 219, 438, 478
Giummarra, M. J., 127 Gyani, A., 475, 476
Givaudan, M., 124
Glaser, R., 127 Haag, A. C., 40
Gleacher, A., 472 Haagsma, J. A., 494
Glisson, C., 477, 479 Hackmann, A., 6, 55, 259, 260, 395
Gluck, T. M., 181 Hadjistavropolous, H. D., 432
Glucksman, E., 35, 40, 386 Hadley, T. R., 479
Gnehm, H. E., 35 Hagborg, J. M., 38
Goenjian, A. K., 36, 401 Hagenaars, M. A., 199
Goldbeck, L., 33, 80, 81, 106, 388, 394, 403 Hahm, H. C., 399
Goldschmidt, L., 38 Haji Ali, A. H., 496
Goldstein, L. A., 352 Haktanir, A., 188
536 Author Index

Hall, B. C., 473 Hinton, D. E., 58, 59, 420, 421, 422, 452
Hall Brown, T. S., 142 Ho, M. S. K., 242
Haller, M., 424 Hodges, L. F., 315
Halligan, S. L., 55 Hoffman, Y. S., 59
Halpern, J. M., 188 Hoffman-Plotkin, D., 39
Halvorsen, J. Ø., 431 Hofman, M., 122
Hamblen, J. L., 182 Hofmann, A., 235, 246
Hamburg, M. A., 334 Hofmann, S. G., 119, 308, 421, 452
Hamby, S., 32, 69, 73 Högberg, G., 242
Hamby, S. L., 31 Hoge, C. W., 19, 199, 216, 217, 260, 344
Han, H., 321, 374, 402 Hoggatt, K., 343
Hanks, C., 236 Holder, N., 184, 477
Hanlon, C., 21 Holdsworth, E., 437
Hanna, D., 388 Holliday, R., 184
Hardin, J., 316 Holliday, S. B., 470
Harik, J. M., 424 Hollon, S. D., 457
Harned, M. S., 189, 191, 198, 199, 200, 221, 374, 417, Holloway, K., 470
418, 430, 471, 472 Holmes, A., 122, 308
Hart, T. L., 182 Holmes, E. A., 55
Harthy, H. A., 242 Holohan, D. R., 457
Hartung, J., 246 Holt, T., 70, 388, 406, 504
Harvey, A., 128, 418 Hoofwijk, M. C., 315
Harvey, A. G., 22, 54, 55, 431, 432 Hoogduin, K. A., 199
Hasler, G., 461 Hopwood, M., 22
Haslett, N., 79, 82 Horesh, D., 419
Hasson-Ohayan, I., 351 Hornsey, M. J., 481
Hatch, S., 18 Horwitz, S. M., 479
Havens, J. F., 69, 403 Hoskins, M. D., 138, 142, 272, 278, 287, 301, 303, 305,
Havermans, R. C., 422 419
Haviland, M. G., 493 Houle, T., 215
Hawkins, K. A., 420 House, K., 32
Hawkins, V., 18 Houston, J. E., 428
Hawley, K. M., 469 Hoven, C. W., 37
Hayden, J. A., 317 Hovey, L. D., 433
Hayes, A. M., 386, 389 Howat, D., 437
Hayes, J. P., 352 Howell, K. H., 34
Hayes, S. M., 352 Hoyt, D., 140
Haynes, R., 98 Hruska, B., 22, 39, 321
Haynes, R. B., 10, 279 Hsiu-Ju, L., 425
Hays, R. D., 221 Huang, L., 72
He, L., 479 Huber, L. C., 216
Healy, E. T., 218, 473 Hughes, M., 20, 417, 492
Hedlund, N. L., 241 Huh, D., 216
Hedman, E., 324 Humayun, A., 59
Hegberg, N. J., 352 Hunt, T. K., 37
Heim, E., 58 Huntley, Z., 61
Heineberg, Y., 401 Huppert, J. D., 189
Held, P., 189 Hurlburt, M. S., 479
Hellhammer, D., 461 Hurley, E. C., 245
Helmers, K., 83 Husted, J. A., 427
Helstrom, A. W., 193 Hutchinson, G., 55
Hembree, E. A., 6, 188, 200, 214 Hutton, P., 376, 389
Henderson-Smart, D., 478 Hyer, L., 184
Hendriks, G., 301 Hyland, P., 57, 61, 368
Hendriks, M., 197 Hyman, S. E., 55
Hendrikz, J. K., 34, 35, 152, 155
Henry, C., 427 Iacoviello, B. M., 17
Hensley, L., 39 Ibrahim, H., 59
Hepner, K. A., 470, 471, 472, 473 Imel, Z. E., 203, 424
Herbst, N., 317 Improving Access to Psychological Therapies,
Herman, P. M., 343 317–318
Herrell, R. K., 19 Inhelder, B., 210
Herschell, A. D., 470, 472, 476 Institute of Medicine, 461
Hetrick, S. E., 275 Institute of Medicine—Committee on Prevention of
Hickie, I. B., 316, 322 Mental Disorders, 118
Hien, D. A., 289, 300, 423, 425 Inter-Agency Standing Committee, 123
Higa-McMillan, C., 455 International Society for Traumatic Stress Studies, 4,
Higgins, J. P., 91, 140, 276, 509 9, 10, 214, 403, 469, 518
Highfill-McRoy, R. M., 419 Ioannidis, J . P. A., 461
Hijazi, A. M., 452 Irie, F., 32
Hiller, R., 81 Irons, C., 371
Hiller, R. M., 34 Ironson, G., 241
Himmerich, H., 242 Isaac, M., 323
Hinton, A. L., 58 Ismail, A. A., 59
Author Index 537

Issakidis, C., 510 Kazak, A. E., 148, 152

ISTSS Guidelines Committee, 366 Keane, T. M., 22, 51, 54, 432
Ivanova, J. I., 493 Kearney, D. J., 347
Ivarsson, D., 327 Keefe, J. R., 460
Iversen, A., 51 Keeler, G., 30
Iversen, T., 504 Keeley, J. W., 52
Iverson, K. M., 226 Kehle-Forbes, S., 437
Iyengar, S., 394 Keller, F., 80, 403
Keller, T., 69
Jablensky, A., 51 Keller, T. E., 32
Jackson, J. L., 423 Kelson, J., 170
Jacob, N., 35 Kemppainen, L. M., 343
Jacobsen, L. K., 321 Kemppainen, T. T., 343
Jacobson, N., 323 Kenardy, J. A., 32, 34, 35, 40, 61, 79, 147, 152, 155, 156,
Jain, S., 372 160, 161, 433
Jak, A. J., 218 Kendall, P. C., 470, 471, 472, 477
Jakupcak, M., 203, 424 Kendall-Tackett, K. A., 39
James, L. E., 326 Kennair, L. E. O., 431
Jang, K. L., 16 Kenney, F. A., 142
Janiaud, P., 461 Keough, M. E., 420
Jankowski, M. K., 22, 428 Kerns, R. D., 22, 432
Jansen, A., 422 Kerridge, C., 140
Jarero, I., 124, 126, 129, 246 Kerssens, J. J., 39
Jarrett, M. A., 433 Kessler, D. S., 281
Jaworski, B. K., 322 Kessler, R. C., 14, 15, 16, 18, 19, 20, 21, 22, 417, 420,
Jayawickreme, N., 197 461, 492
Jaycox, L., 80, 241, 385, 399, 400, 433 Keyes, K. M., 433
Jensen, J. A., 242 Khantzian, E. J., 422
Jensen, T., 70, 73, 80, 81, 106, 109, 241, 385, 433 Khoury, B., 348
Jensen, T. K., 33, 388, 389, 394, 406, 504 Kiecolt-Glaser, J. K., 127
Jensen-Doss, A., 436 Kienzler, H., 58
Jerome, L., 304 Killeen, T. K., 221, 321, 424, 425
Jia, L., 479 Kilmer, B., 510
Jiang, T., 13 Kilpatrick, D., 73
Jimenez-Chafey, M. I., 452 Kilpatrick, D. G., 14, 19, 23, 421
Jobes, D. A., 221 Kim, B. N., 37
Johnides, B. D., 226 Kim, H. K., 39
Johnsen, M. C., 39 Kim, S. J., 201
Jonas, D., 334 Kim, W., 38
Jones, C., 55, 122 Kimerling, R., 437
Jones, D. J., 37 King, D. W., 54, 419
Jones, N., 221, 418 King, L. A., 54, 419
Jones Alexander, J., 51 Kirchner, J. E., 482
Jongmans, M. J., 35 Kirmayer, L. J., 58
Jonsson, B., 495 Kisimoto, J., 193
Jorm, A. F., 322 Klaschik, C., 452
Joseph, S., 386 Klassen, B. J., 189
Joy, D., 125 Kleber, R. J., 32, 34, 35, 122, 242
Jungbluth, N., 475 Kleiboer, A., 138
Juruena, M. F., 427 Kleim, B., 261
Klein, B., 317
Kabat-Zinn, J., 346 Kleindienst, N., 375
Kahler, C. W., 221 Kligler, B., 343
Kaltner, M., 32 Kline, A. C., 188, 287
Kaminski, P. L., 61 Kline, K. D., 320
Kamphuis, J. H., 125, 182, 247 Knaevelsrud, C., 327
Kana, K., 31 Knapp, R. G., 428
Kaplow, J., 76, 80 Knefel, M., 57, 181, 370, 371
Kaplow, J. B., 36 Knies, S., 495
Karam, E. G., 18, 19, 20, 152, 159 Knutsen, M. L., 388
Karatzias, T., 152, 180, 181, 365, 368, 369, 370, 371, Kobulsky, J. M., 38
376 Koczwara, B., 316, 326
Karayan, I., 401 Koenen, K. C., 13, 15, 17, 18, 20, 21, 180, 374, 402,
Karl, R., 216 403, 462, 492
Karlin, B. E., 218, 469, 473, 474, 478 Koerssen, R., 70, 390
Karnon, J., 496 Kohila, M., 35
Karunakara, U., 452 Kolko, D. J., 470, 476
Kashdan, T. B., 425 Komproe, I. H., 59
Kassam-Adams, N., 35, 36, 40, 76, 78, 79, 80, 117, 147, Konig, J., 216
148, 149, 151, 156, 157, 159, 160, 161, 433 Kordte, K. J., 13
Kataoka, S., 152, 400 Korn, D. L., 237, 244
Katz, J., 22, 431 Korslund, K. E., 200, 221, 374, 430, 471
Kaufman, J., 21, 82 Kosten, T. R., 322
Kaysen, D., 210, 216, 217, 317, 420, 423, 452, 474 Kovess-Masfety, V., 72
538 Author Index

Kozak, M. J., 179, 189 Leonard, S., 402, 403

Kozel, F. A., 217, 295, 306 Lester, D., 321
Kraemer, H. C., 459 Lester, K., 216
Kramer, D. N., 153, 156, 159 Levin, A., 473
Kramer, T. L., 475 Levine, P. A., 350
Kravetz, S., 351 Lewin, J., 282
Kredlow Acunzo, M. A., 431 Lewis, C., 90, 106, 109, 123, 139, 169, 170, 192, 260,
Kretschmar, J. M., 16 314, 317, 318, 319, 320, 326, 328, 332, 333, 334, 335,
Kristian Hjemdal, O., 38 418, 420
Kroesen, K., 344 Lewis, C. C., 478
Krumeich, A., 422 Lewis, J., 218, 431
Krupnick, J. L., 319, 328, 373 Lewis, S., 69, 70, 71, 72, 83, 84
Krysinska, K., 321 Lewis, S. J., 31
Kuhl, E., 51 Lewis-Fernandez, R., 58, 59
Kuhn, E., 319, 322, 328 Li, F. W., 128
Kuiken, D., 238 Li, J., 317, 417
Kupfer, D., 51 Li, L., 37, 38
Kusters, W. J. C., 301 Libby, D. J., 354
Kvernmo, S., 37 Lieberman, A., 36
Kwon, H., 58 Lina, G., 323
Lindauer, R. J. L., 399
La Greca, A. M., 37, 149 Lindefors, N., 324
Lai, B. S., 36 Linehan, M. M., 200, 221, 374, 430, 471
Lam, W. W., 119, 120 Liness, S., 421
Lamarche, L. J., 55 Link-Malcolm, J., 216
Lambert-Harris, C., 425 Lipper, S., 282
Lamoureux-Lamarche, C., 492 Lipsey, T. L., 19
Lancee, J., 55 Littleton, H., 17, 320, 328
Landin-Romero, R., 235, 236 Litvin, J. M., 61
Landolt, M. A., 31, 32, 35, 40, 73, 153, 155, 156, 159 Litz, B. T., 119, 215, 245, 260, 291, 301, 302, 308, 320,
Lane, S. D., 425 329, 334, 344
Lanfredi, M., 429 Liu, J., 189
Lang, A. J., 170, 345, 346, 347, 348, 350 Liu, L., 348
Lang, J., 32 Liu, X., 60
Lang, J. M., 76, 79 Livesley, W. J., 16
Lang, P. J., 210 Livingston, J. A., 423
Langdon, K., 478 Ljotsson, B., 324
Lange, A., 126, 327, 343 Ljungman, G., 129
Langley, A. K., 35, 152, 400 Ljungman, L., 129
Lanius, R. A., 51 Ljungstrand, P., 322
Lansing, K., 236 Lloyd, D., 181, 218, 226
Lapsley, H., 510 Lockwood, E., 417, 419, 436
Lareef, I., 479 Loeum, J. R., 58
Larkby, C., 38 Lohrmann, T., 128
Laska, K., 203, 424 Lok, A., 319
Laub, B., 124, 126, 129 Long, D. A., 61
Laugharne, J., 236, 241, 242 Lord, K. A., 226
Laurens, K. R., 427 Lorenzo-Luaces, L., 457, 460
Layard, R., 475 LoSavio, S. T., 477
Layne, C. M., 36, 400, 401 Lovell, K., 192, 373
Le, Q. A., 499 Lozano, B. E., 426
Le Brocque, R., 32, 34, 61, 152, 155, 159 Luber, M., 126
Leboyer, M., 427 Lubman, D. I., 433
Lee, C., 169, 234, 399, 420, 474 Luborsky, L., 451
Lee, C. W., 235, 238, 241, 242, 399 Luce, K. H., 325
Lee, D., 437 Lucerini, S., 321
Lee, D. A., 22 Lucia, V. C., 19
Lee, D. J., 216, 287 Lucid, L., 479
Lee, F. S., 462 Luedtke, A., 461
Lee, M. J., 471 Lueger-Schuster, B., 57, 181
Leeds, A. M., 237, 244 Lugtenberg, M., 418
Lefkowitz, C. M., 193 Luitse, J. S., 315
Lehavot, K., 221, 424 Lund, C., 478
Lehman, C. L., 417 Lunney, C. A., 199, 344, 348
Lehrer, D. S., 427 Lydiard, R. B., 421
Lei, H., 455 Lynch, C. E., 475
Leiter, J., 39 Lynch, K., 455
Lemgruber, V. B., 427 Lyon, A. R., 475
Lempa, W., 235
Lemus, E. L., 197 MacDonald, D. E., 39
Lennon, J. M., 400 Maclean, J. C., 480
Lennox, A., 127 Macleod, A. C., 79
Lenz, A. S., 188 MacMillan, H. L., 72
Leon, A. C., 461 Maercker, A., 15, 49, 54, 55, 58, 61, 268
Author Index 539

Magruder, K. M., 117, 118 McLeod, B. D., 472

Maguen, S., 476 McManus, F., 6, 55, 259, 395, 472
Mahoney, A., 376, 377 McMullen, J., 394, 453
Mahoney, K., 402 Medical Research Council, 320
Maier, T., 31, 73 Medicine, M., 492
Maieritsch, K. P., 217 Meier, A., 425
Mallon, S., 425 Meijer, A. M., 399
Mallonee, S., 469, 470, 471, 472 Meinlschmidt, G., 461
Malte, C., 347 Meiser-Stedman, R., 35, 36, 40, 50, 69, 70, 82, 149,
Manchia, M., 462 366, 386, 387, 388, 390, 395
Mancill, R. B., 417 Melhem, N. M., 36
Mancini, A. D., 119 Mellman, T. A., 142
Mancino, M. J., 494 Meltzer-Brody, S., 60
Mandell, D. S., 479 Melvin, G. A., 35
Manger, T. A., 433 Mendez, M. Z., 183
Maniglio, R., 427 Meng, Q., 479
Manji, H., 461 Mennis, J., 424
Mannarino, A. P., 387, 390, 394, 399, 405, 473 Merchant, L., 475, 480
Mansell, W., 418, 434 Merikangas, K., 72
Maples-Keller, J., 201, 287, 306 Merrill, K. M., 199
Marans, S. R., 153 Merritt, C., 258
March, J. S., 400 Merz, J. F., 221
March, S., 148, 160 Mesa, F., 218
Marchette, L. K., 418, 434 Meuli, M., 155
Marcus, S. C., 471, 473 Mevissen, L., 399
Marcus, S. V., 243 Meyer, I. H., 428
Markon, K., 54, 55 Meyer, W., 405
Markowitz, J. C., 192, 194, 373 Meyers, L. L., 499
Marks, I., 318 Miall, D., 238
Marmar, C. R., 216, 260, 344 Michael, T., 55
Marques, L., 216, 452 Mihalopoulos, C., 492, 499, 500, 505, 510
Marquis, P., 243 Mikulincer, M., 20
Marsac, M. L., 35, 36, 40, 149, 150, 151, 156, 160, 161 Miller, B. J., 427
Marshall, R. D., 275, 277 Miller, W. R., 224
Marsteller, F., 193, 241 Miller-Graff, L. E., 34
Martenyi, F., 277 Mills, K. L., 198, 200, 221, 417, 418, 422, 423, 425
Martin, P., 434 Miner, A., 329
Martinez, M., 347 Mintz, J., 451
Martins, C. M., 427 Miranda, R., 321
Marx, B. P., 216, 218 Mitchell, J. T., 123
Mason, S., 127 Mitchell, K. S., 184, 217, 226, 349
Mataix-Cols, D., 301, 303, 318 Mitchell, R., 388
Matheson, S. L., 427 Mithoefer, A. T., 304
Mathieu, F., 427 Mithoefer, M. C., 292, 293, 304, 305, 309
Matsuzaka, C. T., 480 Moffitt, T. E., 433
Matulis, S., 404 Mohler-Kuo, M., 31, 73
Mavissakalian, M., 184, 226, 299, 309 Monson, C. M., 3, 6, 106, 109, 169, 172, 181, 182, 183,
Mavranezouli, I., 492 184, 193, 210, 211, 214, 216, 218, 221, 227, 315, 317,
Mavridis, D., 509 385, 420, 432, 438, 472, 473, 476, 518
Maxfield, L., 184 Montel, S., 431
Mayou, R., 386 Moonens, I., 123
McArdle, J. J., 419 Mooren, T. M., 242
McCann, R. A., 316 Mooren, T. T., 34
McCauley, J. L., 425 Moos, R. H., 221
McCrone, P., 505 Mor Barak, M. E., 473
McDermott, K., 347 Morgan, F., 356
McEvoy, P. E., 18 Morina, N., 59, 70, 390, 391
McFarlane, A. C., 35, 54, 55, 58, 120, 344, 492 Moritz, G., 36
McFarr, L. M., 473 Morland, L. A., 217
McGlashan, T., 119 Morrongiello, B. A., 32
McGovern, M. P., 425 Mortensen, E. L., 300
McGregor, L. S., 35 Mørup Ormhaug, S., 70, 388
McGuinn, M., 32 Moser, J. S., 200
McGuire, A., 494 Mostoufi, S. M., 248
McHugh, R. K., 469 Mott, J. M., 215, 481
McHugh, T., 22 Motta, R. W., 433
McIlvain, S. M., 218 Moulds, M., 128
McKay, M. M., 481 Moulds, M. L., 129, 180
McKinnon, A., 82 Mouthaan, J., 60, 124, 130, 131, 315, 326
McLaughlin, K. A., 17, 31, 32, 35, 39, 71, 117, 433 Moyers, T. B., 224
McLean, C., 81 Mroczek, D., 118
McLean, C. P., 193, 198, 199, 200, 201, 202, 388, 390 Muche, R., 394
McLean, L. M., 429 Muenzenmaier, K., 428
McLennan, J. D., 72 Mueser, K. T., 181, 417, 426, 427, 428, 429, 430, 431
540 Author Index

Muftic, L. R., 32 Oehen, P., 293, 304, 305

Muir Gray, J. A., 10, 98, 279 Ogden, R. T., 459
Mullen, K., 184 Oh, D.-H., 236
Müller, M., 417, 418 Oh, I., 38
Muller, R. T., 389 Okkels, N., 427
Muraoka, M. Y., 241 Olatunji, B. O., 22, 321
Murdock, T. B., 6, 188 Oldham, M., 277
Murphy, C. M., 438 Olff, M., 60, 61, 106, 109, 117, 130, 137, 169, 170, 182,
Murphy, D., 314, 420 183, 197, 241, 314, 315, 319
Murphy, J., 57, 428 Olin, C. C., 474
Murphy, R., 389 Ollendick, T. H., 433, 434
Murphy, S. A., 455 Olsson, K., 155
Murray, C. J., 494, 495 Olthuis, J. V., 317, 455
Murray, H., 258, 262 Ooi, C. S., 401
Murray, L. K., 181, 417, 434, 435, 436, 474, 475 Opmeer, B. C., 399
Murray, M. C., 400 Ormhaug, S. M., 73, 388, 389, 504
Muse, K., 472 Ormrod, R. K., 32
Myers, U. S., 424, 425 Orsillo, S., 262
Myhre, M. C., 38 Oslin, D., 455
Mystkowski, J. L., 434 Otis, J. D., 22, 432, 433
Otto, M. W., 427, 452
Nacasch, N., 193, 196, 200 Ougrin, D., 472
Nadeem, E., 472 Ouimette, P., 221
Nader, K., 138 Ovenstad, K. S., 389
Nahum-Shani, I., 455 Owen, J. E., 322
Najavits, L. M., 300, 418, 423, 424, 425 Owens, G. P., 217, 218
Nakashima, J., 246 Owens, J. A., 32
Naoom, S. F., 470 Ozer, E. J, 19
Näring, G. W. B., 61
Nasland, J. A., 21 Pacella, B. J., 117, 137, 241, 315
National Center for Complementary and Integrative Pacella, M. L., 22, 39, 193, 200, 321
Health, 343, 344, 345, 359 Pacula, R. L., 510
National Collaborating Centre for Mental Health, 139, Pagani, M., 235, 236
277, 281 Pagura, J., 430
National Institute for Health and Care Excellence, Pai, A., 14
8, 152, 188, 314, 493, 496, 497, 500, 506, 508, 509, Palm, K. M., 371
510, 511, 512 Palosaari, E., 34
National Institute for Health and Clinical Excellence, Panagioti, M., 419
91, 94, 122 Pape, J. C., 462
Neff, K. D., 371 Parker, A., 238
Nelson, C. B., 20, 417, 492 Parker-Guilbert, K., 184, 217
Nemeroff, C. B., 462 Parkin, E., 478
Neria, Y., 373, 463 Parkinson, R. B., 218
Neuner, F., 35, 59, 452, 474 Parslow, R., 275
Newcombe, R. G., 125 Pastor, P., 72
Newman, E., 371 Patel, V., 21, 474
Newman, L. K., 35 Pat-Horenczyk, R., 152, 401
Newman, M. G., 318 Paul, G. L., 451
Ng, M. Y., 452, 461 Paul, L., 427
Nicholas, R., 221 Paulus, M. P., 462
Nickerson, A., 452 Paxton, M. M., 472
Nidich, S., 347, 353 Paxton Willing, M. M., 469, 472
Niemann, L., 348 Payne, P., 350
Nievergelt, C. M., 462 Pearce, J., 317
Nijdam, M. J., 183, 241, 242 Pears, K. C., 39
Niles, B., 343 Pearson, A. N., 371
Niles, B. L., 347 Pearson, C. R., 216, 217
Nishith, P., 193, 214 Pearson, M. R., 423
Nissley, J. A., 473 Pedersen, C. B., 427
Nixon, R. D. V., 128, 129, 180, 210, 216, 317, 387, 420 Pedersen, D., 58
Noordhof, A., 182, 247 Pelcovitz, D., 402
Nordentoft, M., 300 Peleg, T., 50
Norman, S. B., 423, 424, 425, 426 Peltonen, K., 34
Norris, F. H., 119, 120 Peltzer, K., 343
North, C. S., 14, 15, 216 Pengpid, S., 343
Novac, A., 51 Pennebaker, J. W., 127
Nshikawa, T., 193 Perel, J. M., 405
Nugent, N. R., 34, 35, 405 Perfect, M. M., 39
Numata, T., 350 Perkonigg, A., 21
Perlick, D. A., 322
O’Brien, L., 70 Perrin, M., 19
O’Callaghan, P., 394, 453 Perrin, S., 387, 397
O’Donnell, M. L., 19, 54, 55, 59, 117, 120, 127, 128, Person Mecca, L., 476
137, 241, 315 Persson, A., 423, 425
Author Index 541

Pervanidou, P., 35 Rauch, S. L., 138

Petermann, F., 402 Raval, H., 267
Peters, L., 422 Raza, G. T., 457
Peterson, A. L., 193 Read, J. P., 221
Petkova, E., 373, 459 Ready, C. B., 389
Petrakis, I. L., 221, 422, 424 Ready, D., 315
Petrie, K., 323 Reed, A. J., 476
Petrou, S., 496 Reed, G. M., 52, 55
Petukhova, M., 18 Reger, G. M., 193, 197, 201, 315
Pfeiffer, E., 81, 388 Regier, D. A., 51
Pfeiffer, P. N., 4 Reiber, G., 321, 493
Phaneuf, K. A., 238 Reigstad, B., 37
Phelps, A., 420 Reinhardt, K. M., 349
Philip, N. S., 462 Reippainen, J. A., 343
Phillips, J., 470 Reist, C., 301
Philpott, R., 50 Reitsma, J. B., 60, 130, 241, 315
Phipps, K. A., 218 Resick, P. A., 6, 50, 172, 181, 192, 193, 200, 210, 211,
Phoenix Australia—Centre for Posttraumatic Mental 214, 216, 217, 218, 219, 221, 226, 265, 404, 430,
Health, 8–9, 123, 188 458, 473
Piaget, J., 210 Resnick, H. S., 23, 421
Pich, V., 58, 420 Ressler, K., 301, 308
Pietrzak, R. H., 19, 21, 119, 120, 422 Reuben, C., 72
Pilling, S., 106, 109 Rexford, L., 215
Pilver, C. E., 354 Rhew, I., 423
Pinchbeck, R. M., 427 Ribbe, D., 76
Pineles, S. L., 248 Richards, D., 325, 335
Pitman, R. K., 138, 421 Richards, J., 241
Podkowirow, V., 36 Richardson, J. D., 417
Pollack, M. H., 58, 420, 421, 422 Richardson, R., 301
Pollet, T. V., 70, 390 Richardson, W., 98
Polusny, M. A., 347 Richardson, W. S., 10, 279
Popiel, A., 275, 289, 298, 307 Ricksecker, E. G., 218, 473
Porta, G., 36 Ridout, B., 170
Powell, B. J., 478 Riggs, D. S., 6, 60, 106, 109, 169, 183, 188, 189, 317,
Power, K. G., 241 350, 397, 420, 452, 469, 470, 481
Powers, M. B., 188 Riggs, S. A., 61
Praglowska, E., 275, 298 Ringel, J. S., 510
Prchal, A., 156, 159 Riper, H., 314
Prendes-Alvarez, S., 462 Rivera, E. I., 452
Preville, M., 492 Riviere, L. A., 19
Price, J., 148 Rizvi, S. L., 217, 226, 430, 458
Price, M., 60, 182, 315 Rizzo, A., 301, 315
Priebe, K., 375 Robb, A. S., 405
Prins, A., 60 Roberts, A. L., 15, 16
Prinstein, M. J., 149 Roberts, L. W., 322
Probert, R., 125 Roberts, N., 58, 90, 139, 169, 192, 317, 319, 334, 369,
Proctor, D., 192 418
Proctor, L. J., 38 Roberts, N. P., 106, 109, 181, 183, 221, 260, 417, 418,
Propper, R. E., 238 420, 423, 424, 426
Proudfoot, J. G., 317 Roberts, P. A., 221, 418
Pruessner, J. C., 461 Robertson, L., 317
Przekop, P., 493 Robertson, M., 61
Przeworski, A., 318 Rodenburg, R., 399
Puckpinyo, A., 343 Rogers, N., 433
Pulikal, J., 431 Rollin, A., 170
Pullmann, M. D., 475, 479 Romer, D., 16
Punamäki, R. L., 34 Rometsch-Ogioun El Sount, C., 431
Purcell, R., 275 Rona, R. J., 54
Putnam, F., 83 Rose, S., 122
Pynoos, R. S., 36, 82, 400, 401 Rosen, C. S., 4, 182, 469, 476, 477, 481, 482
Rosenbaum, S., 352
Qi, W., 130 Rosenberg, H. J., 428
Qouta, S. R., 34 Rosenberg, L., 405
Rosenberg, M., 405
Rafferty, H., 394, 453 Rosenberg, S. D., 426, 428
Raftery, J., 495 Rosenberg, W., 98
Ragsdale, K. A., 199 Rosenberg, W. M., 10, 279
Rahman, A., 21, 474 Rosenblat, O., 126
Rakovshik, S. G., 472 Rosenfield, D., 81, 200, 301, 303, 308, 388, 390
Ramirez, M., 150, 152, 159 Rosengard, C., 142
Ramsey, K. M., 322 Rosenheck, R. A., 19, 422
Rapee, R. M., 241 Rosner, R., 80, 216, 241, 385, 390, 394, 404, 433
Ratcliffe, J., 494 Ross, J., 422
Rauch, S. A., 4, 200, 299, 307 Rossi, R., 429
542 Author Index

Rossler, W., 343 Schauer, E., 35

Rost, C., 246 Schauer, M., 452
Rostaminejad, A., 246 Scheck, M. M., 241, 242, 243
Rostaminejad, M., 246 Scheeringa, M. S., 33, 34, 35, 36, 37, 40, 79, 82, 390,
Rothbaum, B. O., 6, 60, 122, 142, 179, 188, 192, 193, 395, 405
201, 210, 214, 237, 241, 242, 243, 264, 287, 290, 292, Schilder, A., 39
296, 301, 302, 307, 315, 387 Schilpzand, E., 83
Rousseau, P.-F., 236 Schlegl, S., 317
Roy, M., 301 Schmalzl, L., 350
Roy-Byrne, P. P., 120, 184, 226, 299, 309 Schmid, M., 402
Rozee, P. D., 55 Schmidt, D. A., 55
Rubin, A., 242 Schmidt, L., 317
Rubin, G., 478 Schmidt, S., 348
Rudy, L., 236 Schmittmann, V. D., 417
Ruggiero, K. J., 73, 197 Schmitz, J. M., 425
Ruglass, L. M., 375, 425 Schmuckermair, C., 308
Ruork, A. K., 189 Schneider, E. C., 418
Rusch, H. L., 463 Schneider, J., 246
Rusch, M. D., 119 Schneider, R. L., 462
Rush, A. J., 210 Schneier, F. R., 275, 290, 298, 307
Rush, S. E., 348 Schnicke, M. K., 210, 265
Rusnack, K., 241 Schnurr, P. P., 19, 22, 182, 193, 199, 200, 226, 260, 344,
Russell, M. C., 234, 237, 245, 246, 399, 420 348, 438, 477, 502
Russo, E., 402 Schnyder, U., 31, 51, 73, 170, 180, 184, 304, 390, 451,
Ruwaard, J., 327 453
Ruzek, J. I., 124, 197, 316, 322, 334, 335, 472 Schoemann, A. M., 320
Ryding, E., 122 Schoenbucher, V., 31, 73
Rytwinski, N. K., 188, 287, 419 Schoenwald, S. K., 480
Scholes, C., 127
Sabella, D., 422 Schrieken, B. A., 126, 315
Sabo, A. N., 429 Schubert, S. J., 234, 235, 243, 246, 399, 420
Sachser, C., 76, 80, 81, 388, 394, 403 Schuck, A. M., 433
Sack, M., 61, 235 Schulpher, M. J., 493, 495
Sackett, D. L., 10, 98, 279 Schulte, A., 400
Sackville, T., 128 Schultz, J.-H., 39
Sadikova, E., 461 Schultz, L. R., 321
Saigh, P. A., 82 Schulz, P. M., 216
Saint Gilles, M. P., 39 Schumm, J. A., 218, 220
Saito, A., 193 Schützwohl, M., 54
Sakai, C., 243 Schwebel, D. C., 32
Salanti, G., 509 Schweitzer, C., 245
Salazar, A. M., 32, 69 Scioli, E., 432
Salazar, L. F., 316 Scragg, P., 22, 61
Saleem, J., 371 Sculpher, M., 496
Salkovskis, P. M., 55 Scur, M. D., 419
Salloum, A., 406, 507 Seal, K. H., 18
Salmenniemi, S. T., 343 Sedlar, G., 475
Salmon, K., 388 Seedat, S., 51
Salmond, C. H., 386 Segal, L., 504
Salomon, J. A., 494 Seng, J., 39
Salters-Pedneault, K., 119 Sennhauser, F. H., 35
Saltzman, W. R., 400, 401 Seow, L. S. E., 428
Salyers, M. P., 428 Seppala, E. M., 349
Sampson, N. A., 18 Serghiou, S., 461
Samson, J. A., 390 Serpell, L., 35, 70
Sanderson, K., 510 Settle, C., 244
Santiago, C. D., 400 Severens, J. L., 495
Santiago, P. N., 19, 119, 120 Shafran, R., 418, 475
Santucci, L. C., 436 Shalev, A., 24, 50, 125, 128, 129, 130, 131, 139, 140,
Sarasua, B., 128 142, 419
Sareen, J., 22, 33 Shamseddeen, W., 36
Sartory, G., 128 Shannon, C., 394, 453
Sassi, F., 494 Shapiro, E., 124, 126, 129
Saunders, B., 69, 73 Shapiro, F., 6, 106, 109, 234, 237, 238, 239, 240, 241,
Saunders, B. E., 23, 31 244, 246, 247, 248, 399, 420
Sawitzky, A. C., 479 Sharan, P., 52
Sawyer, M., 72 Sharma, M., 348
Saxe, G., 76, 79 Sharma, R., 356
Saxena, S., 55 Sharp, S., 405
Sayed, S., 17 Sharp, T. J., 22, 431, 432
Sayer, N. A., 479, 480 Shattuck, A., 31, 69, 73
Saylor, C. F., 79 Shaw, B. F., 210
Schaeffer, J. A., 241 Shaw, R. J., 125, 128
Schäfer, I., 418, 423, 424 Shear, J., 347
Author Index 543

Shear, M. K., 36 Spinazzola, J., 33, 59, 428

Shearer, J., 507, 509 Spitzer, C., 22
Shemesh, E., 200 Sporn, J., 405
Shepherd, A. M., 427 Spreeuwenberg, P. M., 39
Shepherd, J. P., 125 Spuij, M., 36
Sherrington, C., 352 Sripada, R. K., 4, 199
Sherwood, A., 492 Stahler, G. J., 424
Shevlin, M., 57, 58, 118, 368, 369, 428 Stallard, P., 150, 155, 159, 388
Shin, L. M., 138 Stams, G. J., 399
Shipherd, J. C., 248 Stander, V. A., 419, 438
Shirk, S. R., 389 Stanley, M. A., 481
Shnaider, P., 182 Stappenbeck, C., 423
Shtasel, D. L., 452 Staron, V., 405
Shvil, E., 463 Steel, C., 429
Siddaway, A. P., 35, 70 Steenkamp, M. M., 119, 120, 215, 260, 344
Sigel, B. A., 475 Steer, R. A., 394
Sijbrandij, M., 60, 125, 128, 129, 130, 137, 138, 315 Steil, R., 375, 404
Sijercic, I., 182, 315 Stein, B. D., 152, 400, 472
Silagy, C., 478 Stein, D. J., 17, 19, 22, 51, 138, 142, 272, 287, 419
Silove, D., 54, 55, 120, 452 Stein, M., 140
Silverman, W. K., 82, 149, 433 Stein, M. B., 16, 422, 462
Simiola, V., 182, 477 Steinberg, A. M., 401
Simms, L. J., 21, 54, 55 Steinberg, K. L., 372
Simon, A., 72 Steinmetz, S. E., 326
Simon, N., 452 Steketee, G., 210
Simon, N. M., 275, 290, 297, 298, 307 Stenmark, H. I., 431
Simpson, T., 423 Stensland, S. Ø., 38, 39
Simpson, T. L., 203, 221, 347, 424, 425 Stergiopoulos, E., 438
Sims-Columbia, A. C., 343 Sternberg, K. J., 38
Sinclair, E., 388 Stewart, L., 50
Singewald, N., 308 Stewart, R. E., 260, 479
Sinha, R., 423 Stewart, S. H., 21, 317
Sivayokan, S., 54 Stickgold, R., 235
Skar, A-M. S., 73 Stiles, A. A., 403
Sklar, M., 479 Stingel, A. M., 427
Skogstad, M., 15 Stirman, S. W., 473, 474, 477, 478, 482
Skopp, N. A., 197 Stoddard, F. J., 32
Slack, K. S., 37 Stoddart, G. L., 493
Slade, E. P., 502 Stokes Reynolds, S., 79
Slade, T., 18 Stolbach, B., 33
Sloan, D. M., 216, 219 Storz, S., 21
Smeets, F., 422 Stovall-McClough, K. C., 321
Smelser, N. L., 178 Stover, C. S., 153
Smerden, J., 83 Stoycheva, V., 347
Smid, G. E., 34 Strauman, T. J., 199
Smith, A. M., 472 Strauss, J., 350
Smith, D., 73 Strauss, J. L., 241
Smith, E., 388 Strecher, V., 455
Smith, K. V., 420 Street, R. L., Jr., 481
Smith, L., 238 Strøm, I. F., 38, 39
Smith, L. J., 425 Struening, E. L., 428
Smith, M. W., 19 Stubbs, B., 352
Smith, P., 35, 40, 267, 386, 387, 388, 395, 397, 401 Studer, L., 461
Smoller, J. W., 461, 462 Su, Z., 459
Sobel, A. A., 218 Substance Abuse and Mental Health Services
Soder, H. E., 463 Administration, 424
Soliman, M. A., 461 Sugar, C. A., 400
Solis, D., 400 Sulaiman, S., 242
Solomon, Z., 20, 419 Suler, J., 323
Somasundaram, D. J., 54, 58, 59 Suliman, S., 138, 142
Sommerfeld, D. H., 479 Sullivan, G. M., 463
Sondergaard, H. P., 235 Sullivan, P. F., 461
Sonne, C., 181, 300 Sultan, M., 31
Sonne, J. L., 493 Sumner, J. A., 22
Sonne, S. C., 423 Sumner, S., 69
Sonnega, A., 20, 21, 417, 492 Sumners, D., 282
Sood, S., 314 Suris, A., 14, 184, 216
Sorbero, M. E., 343 Suvak, M. K., 182, 193, 214, 218, 219, 226
Sousa, J., 470 Suzuki, A., 235
Southwick, S. M., 19, 119, 273, 322, 422 Sveen, J., 319
Speicher, S. M., 218 Swart, M. L., 55
Spek, V., 317, 332 Swenson, C. C., 79
Spence, J., 329, 334 Swift, J. K., 184
Spence, S. H., 79, 241 Szafranski, D. D., 60, 425
544 Author Index

Taft, C. T., 438 Vaccarino, V., 22

Taillieu, T. L., 33 Valentine, J. D., 19
Talkovsky, A. M., 348 Valentine, S. E., 216, 452
Tang, Y., 287 van Dam, D., 60, 424, 425
Tanielian, T., 470 van de Schoot, R., 242
Tarpey, T., 459 van de Ven, J.-P., 126
Tarquinio, C., 431 van den Berg, D. P., 241, 429
Tarrier, N., 419 van den Bout, J., 55
Tate, L., 188, 317, 350, 397, 420 van den Hout, M. A., 235
Tay, A. K., 452 van der Aa, N., 183
Taylor, C. B., 325 van der Kolk, B. A., 33, 59, 241, 242, 349, 428
Taylor, D. M., 278 van der Mast, R. C., 34
Taylor, F., 70 van der Meer, C. A., 315, 319
Taylor, G., 238 van der Schoot, T. A., 32
Taylor, M., 79 van der Zee, J., 39
Taylor, S., 16, 22, 241, 242, 352, 431 van Emmerik, A. A., 125, 126, 128, 129, 182, 247
Taylor, S. L., 343, 354 van Ginkel, J. R., 32
Teesson, M., 422 Van Meter, P. E., 373
Teicher, M. H., 390 van Minnen, A., 196, 197, 198, 199, 221, 301, 417, 418,
Teichman, Y., 275, 298 419, 420, 421
Teng, E. J., 420, 421, 438, 481 van Ommeren, M., 59
Ter Heide, F. J., 183, 242 Van Praet, K., 123
Testa, M., 423 van Schagen, A. M., 55
Theorell, T., 235 van Stolk-Cooke, K., 60
Thirthalli, J., 343 van Straten, A., 314, 317, 460
Thomas, C., 405 van Wesel, F., 35
Thompson, K., 155 van Woudenberg, C., 183
Thompson, R., 477, 482 van Zuiden, M., 319
Thomsen, C. J., 419 Vancampfort, D., 352
Thoresen, S., 30, 32, 38, 39, 117 Vandekerckhove, P., 123
Thorp, S., 345, 346, 348 Vanderburg, D. G., 405
Tidefors, I., 38 Vanderminden, J., 73
Tiedemann, A., 352 Vandermorris, A. K., 15
Tiemens, B., 460 Varela, R. E., 39
Tiet, Q. Q., 182, 221 Varese, F., 427
Tinker, R. H., 237, 243 Varkovitzky, R. L., 218
Tkachuck, M. A., 189 Vasiliadis, H. M., 492
Tol, W. A., 3, 401 Vaughan, K., 241, 242
Tolin, D. F., 22, 262, 321 Vazquez-Montes, M., 472
Torrance, G. W., 493, 494 Vedel, E., 60, 424, 425
Traber, R., 304 Veltman, M. W., 39
Trabjerg, B., 427 Verdeli, H., 21, 474
Tracy, M., 119 Verduin, M. L., 423
Tran, U. S., 57 Verhofstadt-Deneve, L., 36
Travis, F., 347 Vernberg, E. M., 148, 149
Tribe, R., 267 Vernon, P. A., 16
Trickett, P., 83 Vick, T., 319
Trickey, D., 35, 70 Villarreal, G., 281
Trottier, K., 39 Vivolo-Kantor, A., 316
Trumbetta, S. L., 428 Vlahov, D., 118
Tsao, J. C. I., 434 Voderholzer, U., 317
Tsuchiya, A., 494 Vogt, D. S., 226, 458
Tsuruta, N., 193 Vojvoda, D., 119, 120
Tuerk, P. W., 193, 197, 294, 305, 503 Vollrath, M. E., 35
Turgoose, D., 314 von Essen, L., 129
Turley, M. R., 39 von Scheele, B., 235
Turner, H., 31, 32, 69, 73 Vujanovic, A. A., 421, 425
Turner, J., 356 Vuolanto, P. H., 343
Turner, S., 22
Turpin, G., 127 Wachen, J. S., 181, 217, 227
Tutus, D., 81, 388, 394 Wade, M., 221
Twentyman, C. T., 39 Wade, T., 316, 326
Wagner, A., 227
United Nations High Commissioner for Refugees, 32 Wagner, A. C., 182
United Nations Office for Disaster Risk Reduction, 31 Wagner, B., 327
Unützer, J., 321, 493 Wagner, M. T., 304
Updegrove, A. H., 32 Walach, H., 348
Uribe, S., 124 Wald, J., 352
U.S. Department of Veterans Affairs, 343, 354 Waldorp, L. J., 417
U.S. Department of Veterans Affairs & Department of Waldrep, E., 316
Defense, 287, 306, 310 Waldrop, A. E., 424
U.S. Public Health Service, 399 Walker, E. A., 492
Author Index 545

Walker, M., 36 Wolfe, R., 426

Walker Payne, M., 36 Wolff, J. C., 433
Wallace, F., 470 Wolitzky-Taylor, K. B., 462
Waller, R., 333 Wolmer, L., 152, 159
Walter, K. H., 217, 218, 219, 220 Wolpe, J., 238
Walters, E. E., 22 Wong, M., 152
Waltman, S. H., 473 Wood, D. P., 503
Walton, D., 192 Woods, B. A., 434
Waltz, T. J., 478 Wooten, V. D., 218
Wambach, K., 242 Workman, M., 275
Wang, P. S., 18, 20 World Health Organization, 5, 31, 34, 49, 83, 91,
Wang, P. S., 321 122, 241, 243, 246, 248, 275, 365, 402, 492,
Wanklyn, S. G., 182 494
Watkins, E., 418 Wright, L. A., 137
Watkins, L. L., 492 Wu, K. K., 128
Watson, D., 21, 55 Wyka, K., 287
Watt, M. C., 317
Watts, B. V., 188, 287, 481 Xie, H., 425, 426
Weathers, F. W., 19, 51, 59, 219, 319, 481
Weaver, T. L., 193, 214 Yaffe, K., 22
Weems, C. F., 395, 405 Yahne, C. E., 224
Weine, S. M., 119 Yang, R., 405
Weiner, J. L., 423 Ybarra, M. L., 332, 333
Weingardt, K. R., 471, 472 Yeh, R., 76, 80, 81, 82, 388
Weinstein, M. C., 494 Yehuda, R., 21, 306, 419, 462
Weis, F., 141 Yi, S., 343
Weiss, B., 57, 459 Yoder, M., 197
Weiss, D. S., 19, 59 Yohanna, J., 39
Weiss, W. M., 216, 435, 438, 452, 474 Yoon, D., 38
Weisz, J. R., 373, 418, 434, 435, 436, 452, 454, 455, 461, Yoon, S., 38
469, 475 Young, A. H., 278
Wells, A., 192, 193, 194 Young, K., 267
Wells, S. Y., 218, 350 Young, M. B., 304, 309
Welsh Government, 476 Youngstrom, E. A., 419
Wentzel-Larsen, T., 32, 38, 39, 70, 388, 389, 406 Young-Xu, Y., 216
Wesselmann, D., 245, 399 Ystrom, E., 35
Wessely, S., 18, 51, 122 Yuan, B., 479
Westert, G. P., 418 Yuen, E. K., 197
Westling, B. E., 322 Yufik, T., 54
Westman, J. G., 434 Yule, W., 35, 40, 79, 386, 387
Wetherell, J. L., 345, 346 Yusko, D. A., 200
White, H. R., 433 Yzermans, C. J., 39
Whitfield, G., 322 Yzermans, J. C., 39
Whitson, M. K., 37, 38
Whittle, N., 308 Zajac, K., 73
Widaman, K. F., 149 Zalta, A. K., 189, 219
Widmer, V., 304 Zammit, S., 427
Widom, C. S., 433 Zandberg, L. J., 196
Wiedemann, M., 261 Zang, Y., 80, 82
Wijma, B., 122 Zaninelli, R., 277
Wijma, K., 122 Zaslavsky, A. M., 18, 461
Wild, J., 262, 269 Zatzick, D., 122, 127, 321
Wilk, J. E., 19, 469, 474, 477, 480, 482 Zawadzki, B., 275, 298
Williams, C., 322 Zayfert, C., 197
Williams, D. R., 17 Zeanah, C. H., 33, 35
Williams, J., 241 Zehnder, D., 155, 159
Williams, L. F., 193, 214, 218 Zeltner, N., 461
Williams, N. J., 477, 479 Zhang, W., 372
Williams, R., 184 Zhang, Y., 76
Williamson, V., 83 Zimbardo, P., 401
Wilson, S., 243 Zinzow, H. M., 427
Wilson, S. A., 237, 243 Zoellner, L. A., 50, 125, 184, 198, 199, 221, 226, 294,
Wiltsey Stirman, S., 225, 460, 469 299, 305, 309, 417, 418, 430, 494, 499
Winston, F. K., 35, 36 Zohar, J., 138
Wisco, B. E., 218 Zorzella, K. P. M., 389
Wittchen, H. U., 18, 21 Zubizarreta, I., 128
Witte, T. K., 59, 219, 319, 481 Zubizarreta, J. R., 461
Wiwa, O., 58 Zucker, B. G., 434
Wizelman, L., 235 Zvolensky, M. J., 421
Wolf, E. J., 199, 344, 462 Zwart, J.-A., 39
Wolf, G. K., 199 Zweig, K. C., 417
Subject Index

Note. Page numbers followed by an f or a t indicate a figure or a table.

Academic performance, 16, 39 screening and, 70–74, 74–83, 79t, 80t, 82t
Acceptability, 323, 335 transdiagnostic interventions and, 434–436
Acceptance and commitment therapy (ACT), 170 trauma exposure and, 69–71
Accessibility of servicers, 321–324, 356–357 See also Complex PTSD in young people
Accidental injury, 31, 298–299, 379. See also Trauma Adults
exposure cost-effectiveness of an intervention and, 496–513,
Active monitoring, 152, 375 498t–507t
Active therapies, 357–358 early interventions and, 111–113
Activity planning, 433 ISTSS guidelines and, 111–114
Acupuncture, 104, 114, 345, 346t, 349. See also pharmacological treatment and, 113, 114
Complementary, alternative, and integrative psychological treatment and, 113–114
(CAI) approaches Affect regulation skills, 57, 174, 237, 371–372
Acute Stress Checklist for Children (ASC-Kids), 78, Afterdeployment.org, 315–316
80t, 83 Age factors, 15–16
Acute stress disorder (ASD), 33, 35–36, 124–128 Aggression, 366–367, 389–390, 423–424
Adaptive information processing (AIP) model, Agitation, 142, 283
234–235, 398–399 Agoraphobia, 37
Addiction, 221, 424–425. See also Substance misuse; Alcohol misuse, 84, 300. See also Substance misuse
Substance use disorders (SUDs) Alcohol use disorder. See Substance use disorders
Additional traumas, 16–17. See also Trauma exposure (SUDs)
Adolescent Dissociative Experiences Scale, 83 Alternative interventions. See Complementary,
Adolescents alternative, and integrative (CAI) approaches
acute stress disorder (ASD) and, 35–36 Amitriptyline, 114, 281
anxiety and, 37 Anger, 214, 389–390
case formulation and treatment recommendations, Anonymity, 322. See also Confidentiality
83–85 Antiadrenergics, 138
comorbidity and, 433–436 Anticonvulsants, 274, 282
complex PTSD in, 385–406, 394t, 404t Antidepressants, 142, 273–274, 283, 405, 419–420
cost-effectiveness of an intervention and, 496–513, Antipsychotics, 274
498t–507t Anxiety
delivery of treatment recommendations and, children and adolescents and, 37
157–162 cognitive processing therapy and, 214
depression and, 36–37 cognitive therapy for PTSD and, 259, 260
diagnosis and, 33 combined psychotherapy and medication and, 301
externalizing behavior, 37–38 early interventions and, 128–129
functional outcomes related to, 38–39 eye movement desensitization and reprocessing
future development in the area of early therapy and, 242
intervention for, 162–163 overview, 23–24, 33
ISTSS guidelines and, 109–111 panic disorder and, 420–422
overview, 8, 40–41 prolonged exposure and, 197, 198–199, 200
preventative and early interventions and, 147–164 Anxiety disorders, 21, 23–24, 37, 198–199
prolonged exposure and, 397–398 Anxiety Disorders Interview Schedule (ADIS), 81
prolonged grief disorder and, 36 Anxiety Disorders Interview Schedule (ADIS-IV):
risk for PTSD and, 69–71 Child and Parent Interview Schedules, 82t

546
Subject Index 547

Appraisals brief interpersonal psychotherapy (brief IPT), 121t

children and adolescents and, 81–82 compared to early interventions, 129–130
cognitive processing therapy and, 263, 264–266 ISTSS guidelines and, 99, 100, 110, 114
cognitive therapy for PTSD and, 173, 176, 255–257, preventative and early interventions for children
256f, 258, 259 and, 154, 155–156
complex PTSD in children and, 387–388 single-session interventions, 112, 122, 170t
See also Beliefs related to trauma See also individual treatment approaches
Assessment Brofaromine, 114
cognitive therapy for PTSD and, 262–263
complex PTSD and, 367, 368–369 Cancer Coping Online, 316, 326
DSM-5 PTSD and, 51 Carbamazepine, 282
eye movement desensitization and reprocessing Cardiff University Traumatic Stress Research Group,
therapy and, 237–238 278–282
ICD-11 PTSD and CPTSD and, 57–58 Case formulation
pharmacological treatment and, 278 children and adolescents and, 83–85
See also Screening cognitive processing therapy and, 267–268
Assimilated beliefs, 212–213, 223 cognitive therapy for PTSD and, 172–173, 176, 258
Attentional bias modification (ABM), 104, 114 See also Collaborative case conceptualization
Attention-deficit hyperactivity disorder (ADHD), 433 Change mechanisms, 334, 388–389, 523
Augmentation strategies, 301–306, 307–308, 309, Checklists, 74–83, 79t, 80t, 82t. See also Assessment;
524. See also Combined psychotherapy and Screening
medication Child advocacy centers, 159
Avoidance Child and Adolescent Trauma Screen (CATS), 76, 77,
children and adolescents and, 83–84, 391–392 80, 80t
cognitive processing therapy and, 172, 223 Child and Family Traumatic Stress Intervention
complex PTSD and, 374–375, 391–392 (CFTSI), 153, 156–157
effectiveness of psychological treatments and, 182 Child Dissociation Checklist, 83
prolonged exposure and, 189–192 Child maltreatment
psychological treatment and, 177–179 borderline personality disorder and, 429–430
traumatic memories and, 177–178 cognitive processing therapy and, 215
Awareness, 265–266 confidentiality concerns in screening and, 73–74
externalizing behavior and, 37–38
Background information, 236–237 eye movement desensitization and reprocessing
Behavior problems therapy and, 242, 243–244
children and adolescents and, 37–38 risk factors and, 15–16, 70
comorbidity in young people and, 433 See also Childhood sexual abuse; Trauma exposure;
complex PTSD in children and, 388, 389–390, Violence exposure
391–392 Child Post-Traumatic Cognitions Inventory (CPTCI),
overview, 33 82–83
See also Externalizing behavior Child PTSD Symptom Scale for DSM-5 (CPSS-5), 76,
Behavioral activation (BA), 100, 113, 121t 77, 80, 80t
Behavioral avoidance, 178–179. See also Avoidance Child PTSD Symptom Scale for DSM-5, interview
Behavioral disorders, 23–24 (CPSS-5-I), 82t
Behavioral experiments, 173, 258–259, 263, 265–266 Child Revised Impact of Event Scale (CRIES), 76, 78,
Behavioral interventions, 172 79t
Beliefs related to trauma Child Stress Disorders Checklist ASD/PTSD (CTSC),
children and adolescents and, 81–82 79t
cognitive processing therapy and, 212–213, 214–215 Child Stress Disorders Checklist—Short Form
eye movement desensitization and reprocessing (CSDC-SF), 79t
therapy and, 238 Child Stress Disorders Checklist–SS (CSDC), 78
See also Appraisals; Cognitions, trauma-related Child Trauma Screen (CTS), 76, 78, 79t
Benzodiazepines, 139, 142, 274 Child Trauma Screening Questionnaire (CTSQ), 79t
Bereavement, 36. See also Prolonged grief disorder Childhood onset PTSD, 181, 243–244
Bilateral stimulation (BLS), 237, 238–240, 245 Childhood sexual abuse, 215, 242. See also Child
Biological factors, 461–463 maltreatment; Sexual abuse; Sexual violence
Biological treatments, 284. See also Neurofeedback; Children
Pharmacological treatments; acute stress disorder (ASD) and, 35–36
Saikokeishikankyoto; Transcranial magnetic anxiety and, 37
stimulation (TMS) case formulation and treatment recommendations,
Bipolar disorder, 426–428 83–85
Blueprint, 258–259 cognitive therapy for PTSD and, 261–262
Body scan, 240 comorbidity and, 433–436
Borderline personality disorder (BPD), 57, 198–199, complex PTSD in, 385–406, 394t, 404t
268, 368–369, 429–431 cost-effectiveness of an intervention and, 496–513,
Breathing training, 125, 175, 192, 502t. See also 498t–507t
Relaxation training delivery of treatment recommendations and,
Brief interventions 157–162
brief CPT, 121t depression and, 36–37
brief CPT-T, 156–157 diagnosis and, 33–35
brief dyadic therapy, 112, 121t externalizing behavior, 37–38
brief eclectic psychotherapy for PTSD (BEPP), 102, eye movement desensitization and reprocessing
114, 170, 170t therapy and, 244–245
548 Subject Index

Children (cont.) complex PTSD in children and, 393, 395–396

functional outcomes related to, 38–39 cost-effectiveness findings and, 501t
future development in the area of early Cognitive strategies and behaviors, 256f, 257, 258–259
intervention for, 162–163 Cognitive therapies, 500t
ISTSS guidelines and, 109–111 Cognitive therapy (CT). See also Cognitive therapy for
overview, 8, 40–41 PTSD (CT-PTSD)
preventative and early interventions and, 147–164 cost-effectiveness findings and, 512
prolonged grief disorder and, 36 ISTSS guidelines and, 101, 112, 113, 121t, 170t
risk for PTSD and, 69–71 overview, 125
screening and, 70–83, 79t, 80t, 82t Cognitive therapy for PTSD (CT-PTSD)
transdiagnostic interventions and, 434–436 combined psychotherapy and medication and, 287
trauma exposure and, 69–71 complex PTSD in children and, 395–397
See also Complex PTSD in young people core elements of, 176–179
Children’s Posttraumatic Stress Disorder Inventory core interventions in, 258–259
(CPTSDI), 82t cost-effectiveness findings and, 501t, 506t
Chronic pain, 355, 431–433. See also Somatic delivery of, 262–269
experiencing evidence that supports, 259–262
Chronicity, 34, 118–120, 119f, 243–244, 260 ISTSS guidelines and, 102
Client readiness, 237, 260–261, 354 overview, 6, 171f, 172–173, 183–184, 255, 521
Clinical Descriptions and Diagnostic Guidelines (CDDG), techniques of, 258–259
53–54 theoretical models and, 255–257, 256f
Clinical presentation, 8, 40–41. See also Symptoms See also Psychological treatment
Clinician-Administered PTSD Scale (CAPS), 51, 346 Cognitive-Behavioral Intervention for Trauma in
Clinician-Administered PTSD Scale for DSM-5— Schools (CBITS), 393, 399–402
Child/Adolescent Version (CAPS-CA-5), 82t Cognitive-behavioral models, 386–389
Clinicians Cognitive-behavioral therapy (CBT)
cognitive processing therapy and, 224–225, 269 adapting for specific populations and
cognitive therapy for PTSD and, 260–261, 263 environments, 452–453
complementary, alternative, and integrative (CAI) children and adolescents and, 386–389, 391–392, 406
approaches and, 355, 356 chronic pain and, 432–433
E-mental health interventions and, 317, 332–333 cognitive therapy for PTSD and, 259
prolonged exposure and, 197–201 combined psychotherapy and medication and, 301
treatment selection and, 457 comorbidity and, 128–129
See also Training complex PTSD and, 376, 386–389, 391–392, 406
Cochrane Collaboration’s risk of bias, 91, 140, 276–277 cost-effectiveness findings and, 502t
Cognitions, trauma-related, 176–177, 387–388, early interventions and, 131
391–392. See also Beliefs related to trauma E-mental health interventions and, 317–318
Cognitive avoidance, 191. See also Avoidance eye movement desensitization and reprocessing
Cognitive Behavioral Intervention for Trauma in therapy and, 241
Schools (CBITS), 434 ISTSS guidelines and, 113, 170t
Cognitive processing therapy (CPT) neurobiological findings and, 463
adapting for specific populations and overview, 170, 521
environments, 452–453 preventative and early interventions for children
cognitive therapy for PTSD and, 260 and, 149
combined psychotherapy and medication and, See also Cognitive-behavioral therapy with a trauma
287, 306 focus (CBT-T); Trauma-focused CBT (TF-CBT)
complex PTSD in children and adolescents and, Cognitive-behavioral therapy with a trauma focus
404, 405–406 (CBT-T)
core elements of, 176–179 acupuncture and, 349
cost-effectiveness findings and, 497, 499t, 501t, 512 brief interventions and, 129–130
CPT + A (written trauma account ), 212, 226 comorbidity and, 128–129
delivery of, 218–225 complex PTSD in children and, 386, 388–389, 394t
depression and, 420 cost-effectiveness findings and, 497, 499t, 501t,
effectiveness of, 268–269 504t, 505t, 506t, 508, 510, 511, 512
evidence that supports, 214–218 in a group format, 111, 113, 170t, 180, 394t, 501t,
future directions, 225–227, 269 504t, 505t
improving treatment effectiveness and, 528 ISTSS guidelines and, 99, 102–103, 110, 111, 112,
ISTSS guidelines and, 102, 113, 170t 113, 121t, 155–157, 170t
multivariable prediction models and, 459–460 overview, 125, 180
neurobiological findings and, 463 preventative and early interventions for children
overview, 6, 128, 171f, 172, 183–184, 210, 269, 521 and, 152–153, 154, 155–157, 158–159
personalized interventions and, 458–459 See also Cognitive-behavioral therapy (CBT)
techniques of, 211–214 Cognitive-behavioral therapy with a trauma focus
theoretical models and, 210–212 (CBT-T) (caregiver), 111
training and, 224–225, 472, 474 Cognitive-behavioral therapy with a trauma focus
treatment selection and, 457 (CBT-T) (child), 111
See also Psychological treatment Cognitive-behavioral written therapy (CBWT), 399
Cognitive restructuring Collaborative assessment and management of
borderline personality disorder and, 430–431 suicidality (CAMS), 220–221
chronic pain and, 432–433 Collaborative care, 112, 121t, 502t
cognitive-behavioral therapy with a trauma focus Collaborative case conceptualization, 174. See also
and, 125 Case formulation
Subject Index 549

Combination treatments, 375–376 Complex PTSD in young people

Combined psychotherapy and medication cognitive-behavioral models and, 386–389
delivery of, 306–308 developmental considerations in treatment,
evidence that supports, 288–306, 289t–295t 389–391
future directions, 308–310 future directions, 405–406
overview, 287–288, 310 overview, 385–386, 402–404
techniques of, 288 pharmacological treatment and, 404–405, 404t
See also Pharmacological treatments; Psychological recommendations regarding treatments for,
treatment; individual treatment approaches 394–399, 394t
Common Elements Treatment Approach (CETA), 435, school-/group-based interventions and, 399–402
436, 474 screening children and adolescents and, 80
Communication facilitator in an intensive care setting, treatment elements and, 391–393, 394t
101, 112, 121t See also Adolescents; Children; Complex PTSD
Community Outreach Program–Esperanza (COPE), Complex trauma, 243–244, 247
401–402 Complex Trauma Inventory (CTI), 61
Community violence, 32, 38–39 Composite moderator approach, 459
Comorbidity Computerized interventions, 101, 113, 121t. See also
in adults, 419–433 E-mental health; Internet-based interventions
with borderline personality disorder, 429–431 Concurrent Treatment of PTSD and Substance Use
case example, 22–23 Disorders Using Prolonged Exposure (COPE),
in children and adolescents, 84, 433–434 375–376
with chronic pain, 431–433 Conduct disorder (CD), 84, 433
cognitive processing therapy and, 217–218, 268–269 Confidentiality, 73–74, 322
cognitive therapy for PTSD and, 260 Consultation, 472–473, 480–481
complementary, alternative, and integrative (CAI) Contextual factors, 15–16, 23–24, 54, 58–59
approaches and, 355 Coping skills
complex PTSD in children and, 399 complex PTSD in children and, 388–389, 392–393,
with depression, 419–420 405–406
early interventions and, 128–129 cost-effectiveness findings and, 498t
effectiveness of psychological treatments and, 181 substance use disorders and, 424–426
future directions, 438 Corticosteroids, 306
improving treatment effectiveness and, 524 Cost-benefit analysis, 259
overview, 8, 21–24, 417–419, 436–438, 437f, 493 Cost-effectiveness of an intervention
with panic disorder, 420–422 complementary, alternative, and integrative (CAI)
prevalence of, 13 approaches and, 356–357
prolonged exposure and, 198–199, 200–201 E-mental health interventions and, 324, 335
with severe mental illness, 426–429 generalizability and transferability of findings and,
with substance use disorders, 422–426 512–513
transdiagnostic interventions and, 434–436 implementation challenges and, 527–528
Compassion meditation, 347–348. See also Meditation limitations of existing evidence, 508–510
Complementary, alternative, and integrative (CAI) overview, 496–513, 498t–507t
approaches See also Health economics
delivery of, 353–358, 358f Country-level violence, 32
evidence that supports, 345–352, 346t Couples CBT with a trauma focus, 113, 170t, 180
future directions, 358–359 Crises, 379–380
improving treatment effectiveness and, 524 Critical-incident stress debriefing (CISD), 123
overview, 343–345, 346t, 359–360 Cultural factors
See also Acupuncture; Meditation; Music therapy; adapting therapies for specific populations and
Nature–adventure therapy; Physical exercise; environments, 451–453
Saikokeishikankyoto; Somatic experiencing; E-mental health interventions and, 325
Yoga eye movement desensitization and reprocessing
Complex PTSD therapy and, 248
assessment and, 57–58, 367, 368–369 overview, 58–59
challenges in the treatment of, 377–380 panic disorder and, 422
combination treatments and, 375–376 personalized interventions and, 457–459
cross-cultural and supra-individual contexts and, training and, 473–474
58–59
diagnosis and, 52–57, 53f, 56f, 62 Davidson Trauma Scale, 60
eye movement desensitization and reprocessing d -Cycloserine (DCS), 301–303, 308, 309, 405
therapy and, 248 Debriefing
International Classification of Diseases (ICD-11) and, ISTSS guidelines and, 99–100, 110, 112, 121t, 155
55–57, 56f preventative and early interventions for children
modular therapies and, 454 and, 150–151, 154
overview, 5, 7, 34, 49, 55–57, 56f, 365–366, 380, Delinquency, 37–38. See also Externalizing behavior
385–386, 520 DElivery of Self-TRaining and Education for Stressful
psychological treatment and, 180 Situations (DESTRESS-PC), 320–321, 327t, 329t
symptoms of to target in treatment, 370–373 Depression
tasks of treatment for, 367–368 children and adolescents and, 36–37, 84
therapeutic frame and, 366–367 cognitive processing therapy and, 214, 217,
treatment approach to, 369–370 219–220, 226, 268
treatment delivery, 373–376 cognitive therapy for PTSD and, 260
See also Complex PTSD in young people combined psychotherapy and medication and, 300
550 Subject Index

Depression (cont.) Dissemination of EBPs, 476–481

comorbidity and, 419–420 Dissociation
complementary, alternative, and integrative (CAI) cognitive processing therapy and, 226, 268
approaches and, 355 complex PTSD and, 366–367, 378–379
early interventions and, 128–129 diagnosis and, 50
eye movement desensitization and reprocessing prolonged exposure and, 198–200
therapy and, 242 Distillation and Matching Model (DMM), 435–436
overview, 21, 22, 23–24, 33, 493 Disturbances in self-organization (DSO), 365–366, 372
personalized interventions and, 458–459 Divalproex, 114
pharmacological treatment and, 278 Docosahexaenoic acid, 113, 138
prolonged exposure and, 197, 198–199, 200 Domestic violence, 15–16, 73–74. See also Trauma
psychotic disorders and, 426–427 exposure
Desensitization, 174, 238–239 Dropout rates, 248, 334, 374–375, 460
Developmental factors, 15–16, 160–161, 389–391 Dual-diagnosis, 422–426. See also Comorbidity
Dexamethasone, 306 Dual-focused attention, 238
Diagnosis Dyadic therapy, 100, 112, 121t
checklists and questionnaires and, 77–83, 79t, 80t,
82t Early intervention
children and adolescents and, 33–34, 70–71, 83 adults and, 111–113
cognitive therapy for PTSD and, 262–263 children and adolescents and, 109–110, 147–164,
complex PTSD in young people and, 402–403 157–163
differential diagnosis, 57, 83–84, 368–369 comorbidity and, 128–129
DSM-5 PTSD, 49–51, 62 compared to brief interventions, 129–130
epidemiology of of PTSD and other psychological future directions, 130–131, 162–163
consequences of trauma exposure and, 18–19 ISTSS guidelines and, 99–101, 109–110, 111–113,
ICD-11 PTSD, 52–57, 53f, 56f, 62 120–128, 121t, 156–157
overview, 5, 49, 62, 520 overview, 6, 117–120, 119f, 124–128
PTSD and, 33–34 pharmacological treatment and, 137–143, 140t
seeking treatment following, 20–21 theoretical models and, 148–153
Diagnostic and Statistical Manual of Mental Disorders See also Interventions; Preventative interventions;
(DSM), 49 Treatment interventions; Treatment
Diagnostic and Statistical Manual of Mental Disorders recommendations; individual treatment
(DSM-IV) approaches
cognitive processing therapy and, 221 Eating disorders, 39
defining traumatic events and, 14–15 Economic evaluations and views, 492–496, 508–510.
epidemiology of of PTSD and other psychological See also Health economics
consequences of trauma exposure and, 18–19 Educational functioning, 16, 39
overview, 5, 50–51 Electracupuncture, 114
Diagnostic and Statistical Manual of Mental Disorders EMDR Protocol for Recent Critical Incidents
(DSM-IV-TR), 14–15 (EMDR-PRECI), 124. See also Eye movement
Diagnostic and Statistical Manual of Mental Disorders desensitization and reprocessing (EMDR)
(DSM-5) therapy
assessment and, 51 E-mental health
children and adolescents and, 78, 83 advantages of, 321–324, 321f
cross-cultural and supra-individual contexts and, clinical recommendations, 331–333
58–59 delivery of, 331–333
defining traumatic events and, 14–15 evidence that supports, 325–331, 327t–330t
diagnosis and, 49–51, 62 future directions, 334–335
E-mental health interventions and, 319 limitations of, 324–325, 324f
epidemiology of of PTSD and other psychological overview, 314–321, 318f, 335–336
consequences of trauma exposure and, 18–19 prevention of PTSD with, 315–316, 325–326
modular therapies and, 454 recommendations regarding, 331–335
overview, 49–51, 62, 520 for the treatment of PTSD, 316–321, 318f, 326–331,
Diagnostic Infant and Preschool Assessment (DIPA), 327t–330t
82t See also Internet-based interventions
Dialectical behavior therapy, 220–221 Emotion regulation difficulties, 376, 432–433. See also
Dialogical exposure therapy (DET), 103, 114, 170t. See Affect regulation skills
also Exposure techniques Emotional abuse, 242
Didactic training components, 470–472. See also Emotional freedom techniques (EFT), 103, 114, 170t
Training Emotional numbing, 366–367, 369
Differential diagnosis, 57, 83–84, 368–369. See also Emotional shifts, 263
Diagnosis Emotional symptoms, 54, 57. See also Symptoms
Disability, 260 Empowerment, 323
Disability-adjusted life year (DALY), 494–496 Engagement
Disasters cognitive processing therapy and, 268
eye movement desensitization and reprocessing cognitive therapy for PTSD and, 260
therapy and, 246 complementary, alternative, and integrative (CAI)
overview, 31 approaches and, 354
preventative and early interventions for children effectiveness of psychological treatments and, 182
and, 148 E-mental health interventions and, 321–324, 332, 334
See also Trauma exposure implementation and dissemination of EBPs and,
Discrimination training, 173, 258, 266–267 481
Subject Index 551

Enuresis, 389–390 modular therapies and, 454

Epidemiology, 13, 14, 18–19, 23–24, 40. See also multivariable prediction models and, 461
Prevalence overview, 6, 123–124, 125–126, 171f, 173–174,
Escitalopram, 113 183–184, 234, 521
Ethical factors, 161–162, 324, 528 psychotic disorders and, 429
Evidence for and against appraisals, 265–266 techniques of, 236–241
Evidence-based psychotherapy (EBP) theoretical models and, 234–236
consultation and, 472–473 See also Psychological treatment
E-mental health interventions and, 321, 331–332
implementation and dissemination and, Family factors, 70, 161
476–481 Family therapy, 111, 394t
overview, 469–470 Fear, 259
training and, 470–476 Fidelity, 183–184, 480–481
Evidence-based treatment (EBT). See also Treatment Financial factors, 324, 335, 356–357
recommendations Flexibility, 322–323, 373, 378, 453–455
adapting for specific populations and Fluoxetine
environments, 451–453 dosing, 277t, 279–280, 279t, 281
combined psychotherapy and medication and, 287, evidence that supports, 275
296, 297–301, 305–306 eye movement desensitization and reprocessing
comorbidity and, 418, 437 therapy and, 241
implementation challenges and, 527–528 ISTSS guidelines and, 114
improving treatment effectiveness and, 524–527 overview, 285
modular therapies and, 453–455 Follow-up care, 368
overview, 7, 184 Functioning, 19–20, 38–39, 54, 423–424
Exercise, physical. See Physical exercise
Experiential avoidance, 177–179. See also Avoidance Gabapentin, 113, 138
Exposure hierarchy, 195–196 Ganaxolone, 114
Exposure techniques Generalized anxiety disorder (GAD), 37, 84. See also
chronic pain and, 432–433 Anxiety
cognitive-behavioral therapy with a trauma focus Genetic factors, 427–428, 461–463
and, 125 German-language Screening for Complex PTSD
combined psychotherapy and medication and, 288, (SkPTBS), 61
301, 305–306 Goals of treatment
complex PTSD in children and, 392–393, 395–396, cognitive processing therapy and, 219–220,
397–398, 405–406 223–224
cost-effectiveness findings and, 501t cognitive therapy for PTSD and, 255, 256f, 257
eye movement desensitization and reprocessing complementary, alternative, and integrative (CAI)
therapy and, 238–239 approaches and, 356
ISTSS guidelines and, 103, 113–114 complex PTSD and, 367–368, 370–373
overview, 6 effectiveness of psychological treatments and,
substance use disorders and, 424–426 181–182
See also Narrative Exposure Therapy for Children GRADE criteria, 140, 276–277
(KidNET); Narrative exposure therapy (NET); Grief, 36. See also Prolonged grief disorder
Prolonged exposure (PE) Group 512 PM, 100, 112, 121t, 123
Exposure to traumatic events. See Trauma exposure Group CBT-T
Expressive art therapy, 111 complex PTSD in children and, 394t
Externalizing behavior, 33, 37–38, 433. See also cost-effectiveness findings and, 501t, 504t, 505t
Behavior problems ISTSS guidelines and, 111, 113, 170t
Eye movement desensitization and reprocessing overview, 180
(EMDR) therapy See also Cognitive-behavioral therapy with a trauma
adapting for specific populations and focus (CBT-T)
environments, 453 Group debriefing, 112, 121t
brief interventions and, 129–130 Group education, 121t
with children and adolescents, 244–245, 386, 394t, Group interpersonal therapy, 114, 170t
398–399, 406, 433–434 Group interventions
cognitive therapy for PTSD and, 260 children and adolescents and, 399–402
combined psychotherapy and medication and, cognitive processing therapy and, 217
287 complementary, alternative, and integrative (CAI)
comorbidity and, 129, 433–434 approaches and, 355–356
complex PTSD in children and, 386, 394t, 398–399, complex PTSD and, 376–377, 399–402
406 cost-effectiveness findings and, 498t
core elements of, 176–179 See also individual treatment approaches
cost-effectiveness findings and, 497, 500t, 505t, Group mindfulness-based stress reduction, 114
511, 512 Group music therapy, 114, 351. See also
delivery of, 243–246 Complementary, alternative, and integrative
depression and, 420 (CAI) approaches; Music therapy
evidence that supports, 241–243 Group psychoeducation, 111, 112, 394t
future directions, 247–248 Group stabilizing treatment, 114, 170t
ISTSS guidelines and, 99, 103–104, 111, 112, 113, Group stress management, 112, 121t
121t, 170t Group supportive counseling, 114, 170t
large-scale training efforts and, 474 Guided discovery, 173, 265–266
limitations of, 246–247 Guilt, 200–201, 214, 237–238, 458–459
552 Subject Index

Health care interventions, 493–496 Intensive care diaries, 101, 112, 121t
Health care settings Intensive delivery of treatment, 269
complementary, alternative, and integrative (CAI) Interapy, 318–319, 318f, 327t, 328t
approaches and, 355 Internalizing symptoms, 433
implementation challenges and, 528 International Classification of Diseases (ICD), 49
preventative and early interventions for children International Classification of Diseases (ICD-10), 78
and, 159–160 International Classification of Diseases (ICD-11)
screening and, 71–72, 74 assessment and, 57–58
Health economics children and adolescents and, 78, 402–403
cost-effectiveness findings, 496–513, 498t–507t complex PTSD and, 7, 365–366, 380, 385, 402–403
determining, 495–496 cross-cultural and supra-individual contexts and,
generalizability and transferability of findings and, 58–59
512–513 diagnosis and, 34, 50–51, 52–57, 53f, 56f, 62
limitations of existing evidence, 508–510 epidemiology of of PTSD and other psychological
overview, 492–496 consequences of trauma exposure and, 19
See also Cost-effectiveness of an intervention; eye movement desensitization and reprocessing
Economic evaluations and views therapy and, 248
Health problems. See Physical health problems overview, 5, 52–57, 53f, 56f, 62
Heart stress counseling, 112, 121t International Society for Traumatic Stress Studies
Hindsight bias, 213, 223, 265–266 (ISTSS) guidelines
History taking, 236–237 adults and, 111–114
Holistic approaches, 526. See also Complementary, children and adolescents and, 85, 109–111,
alternative, and integrative (CAI) approaches 153–164, 162–164
Homework between sessions, 195, 212 classification and grouping of interventions,
Homicidality, 220–221 98–106
Hot spots, 264–265 clinical importance and, 94–95
Hydrocortisone, 113, 138, 141 cognitive therapy for PTSD and, 259–260
Hypnotherapy, 104, 114 combined psychotherapy and medication and,
288, 310
Imagery techniques, 265–266, 501t committee for the development of, 106
Imaginal exposure comorbidities and, 418–419
cognitive-behavioral therapy with a trauma focus complementary, alternative, and integrative (CAI)
and, 125 approaches and, 345, 346t
combined psychotherapy and medication and, complex PTSD in children and, 385–386, 394t
305–306 cost-effectiveness findings and, 512–513
complex PTSD in children and, 392–393 delivery of treatment recommendations to children
delivery of, 195 and adolescents and, 157–162
overview, 175, 191–192 early interventions and, 109–110, 111–113, 120–128,
prolonged exposure and, 174–175 121t, 155–157
substance use disorders and, 425 eye movement desensitization and reprocessing
See also Exposure techniques; Prolonged exposure therapy and, 241, 242
(PE) future directions, 528–529
Imaginal reliving, 264–265, 396 interpreting, 97–98
Imipramine, 114 member consultation, 97
Impact of Event Scale (IES), 126 modular therapies and, 454
Impact of Event Scale–Revised (IES-R), 59–60 overview, 4, 8–10, 90–92, 109, 118, 120–128, 121t,
Implementation of treatment 518–519, 520
challenges in, 527–528 pharmacological treatment and, 111, 113, 114, 139,
contextual factors in, 476–481 140t, 141, 274–278, 276t
improving treatment effectiveness and, 524–527 prevention and early interventions and, 120–128,
overview, 469–470, 482–483 121t, 153–162, 155–156
Improving Access to Psychological Therapies (IAPT) prolonged exposure and, 192–194
Program, 469–470, 475–476 psychological treatment and, 110–111, 113–114,
In vivo exposure 169–170, 170t, 183–184
chronic pain and, 432–433 recommendation setting, 95–97
cognitive-behavioral therapy with a trauma focus scoping questions, 91, 92, 97–98, 107–108, 109–114,
and, 125 276, 288
complex PTSD in children and, 392–393, 395–396 systematic reviews and meta-analyses, 92–94
delivery of, 196 See also Treatment recommendations
overview, 175, 190–191 International Trauma Interview (ITI), 58, 369
prolonged exposure and, 174–175 International Trauma Questionnaire (ITQ), 57–58,
substance use disorders and, 425 61, 369
See also Exposure techniques; Prolonged exposure (PE) Internet-based interventions
Index trauma, 223–224 Internet virtual reality therapy, 100, 113, 121t
Information processing paradigms, 176–179, 521–524 Internet-based CBTs (i-CBT), 330–331
Informed consent, 236–237 Internet-based CBT-T, 102–103, 170, 170t, 180, 512
Injuries, 31, 298–299, 379 Internet-based guided self-help, 112, 121t, 124, 126,
Insomnia, 142, 282–283 151, 154
Installation, 239–240 overview, 170
Integrative interventions, 425. See also personalized interventions and, 455–456
Complementary, alternative, and integrative preventative and early interventions for children
(CAI) approaches and, 160
Subject Index 553

self-directed psychoeducation, 110, 154, 155 eye movement desensitization and reprocessing
self-guided Internet-based intervention, 101, 112, 121t therapy and, 237–238, 245–246
Trauma TIPS, 124 large-scale training efforts and, 474–476
See also E-mental health Mind–body skills, 105, 111. See also Complementary,
Internet-based training, 471–472. See also Training alternative, and integrative (CAI) approaches
Interpersonal functioning, 372–373 Mindfulness-based interventions, 524
Interpersonal psychotherapy (IPT) Mindfulness-based stress reduction (MBSR), 105, 114,
complex PTSD and, 372–373 346–348. See also Meditation
cost-effectiveness findings and, 497, 500t Mirtazapine, 114, 142, 281, 283
ISTSS guidelines and, 100, 104, 112, 114, 121t, 170t Modular Approach to Therapy for Children with
modular therapies and, 454 Anxiety, Depression, Trauma, or Conduct
overview, 122 Problems (MATCH-ADTC), 434–436
prolonged exposure and, 194 Modular therapies, 453–455
Interpersonal trauma Monamine reuptake inhibitors (MARIs), 273
children and, 35 Monitoring, active. See Active monitoring
eye movement desensitization and reprocessing Monoamine oxidase inhibitors (MAOIs), 273
therapy and, 242–243 Mood disorders, 21, 23–24, 426–427
interpersonal violence, 38–39, 433 Mood stabilizers, 282
overview, 31 Morphine, 139
risk for PTSD and, 70 Multidisciplinary Association for Psychedelic Studies
See also Trauma exposure (MAPS), 304
Interventions, 98–106, 524–527. See also Early Multimodality Trauma Treatment, 400
intervention; Treatment interventions; Multimodular approach, 373–375
Treatment recommendations; individual Multiple channel exposure therapy (M-CET),
treatment approaches 421–422
Intrusive memories, 257, 266–267. See also Traumatic Multiple-session interventions, 122–123, 124
memories Multivariate prediction models, 459–461
Item response theory (IRT) modeling, 58 Music therapy, 114, 345, 346t, 351. See also
Complementary, alternative, and integrative
Ketamine, 114 (CAI) approaches
Kiddie Schedule for Affective Disorders and My Disaster Recovery, 316, 326
Schizophrenia (K-SADS), 81, 82t
KidNet. See Narrative Exposure Therapy for Children Narrative Exposure Therapy for Children (KidNET)
(KidNET) complex PTSD in children and, 393, 394t
ISTSS guidelines and, 111, 156–157
Lamotrigine, 114, 282 preventative and early interventions for children
Legal problems, 268, 324 and, 153, 156–157
Life Skills, Life Stories program, 402 See also Exposure techniques; Narrative exposure
Life stressors, 379–380 therapy (NET)
Lifestyle interventions, 522 Narrative exposure therapy (NET)
Loss, 31. See also Trauma exposure adapting for specific populations and
environments, 452
Maintenance, 357, 368 cost-effectiveness findings and, 501t, 505t
Major depressive disorder (MDD), 419. See also ISTSS guidelines and, 103, 113, 170t
Depression overview, 170
Manic episodes, 426–427 training and, 474
Mantram repetition program (MRP), 104, 114, See also Exposure techniques; Narrative Exposure
345–346. See also Complementary, alternative, Therapy for Children (KidNET)
and integrative (CAI) approaches; Meditation Narrative therapies, 403–404
Massed prolonged exposure, 201–202. See also Narratives, trauma, 393, 403–404. See also Written
Prolonged exposure (PE) trauma accounts
MDMA (3,4-Methylenedioxy-m), 303–305, 308, 309, National Child Traumatic Stress Network (NCTSN),
405, 524 475
Meditation National Institute for Health and Care Excellence
evidence that supports, 345–348, 346t (NICE) treatment guidelines, 475–476, 495–496,
improving treatment effectiveness and, 524 510–512
ISTSS guidelines and, 104, 114 Natural recovery following trauma exposure, 17–18,
overview, 345 118–120, 119f, 162
See also Complementary, alternative, and Nature–adventure therapy, 114, 345, 346t, 351. See also
integrative (CAI) approaches; Mindfulness- Complementary, alternative, and integrative
based stress reduction (MBSR) (CAI) approaches
Memories and memory processing, 173–174, 234–236, Negative appraisals, 256–257, 387–388. See also
235, 238–241. See also Traumatic memories; Appraisals
Updating trauma memories procedure Negative self-concept, 371
Mental health services, 158–160 Neurobiology, 272–273, 461–463
Mental illness, severe, 426–429, 431. See also Psychosis Neurofeedback, 105, 114, 284
and psychotic disorders Neurokinin-1 antagonist, 114
Metacognitive therapy (MT), 105, 194 Nondirective counseling, 111, 394t. See also
Methyleneblue, 305–306 Supportive/nondirective counseling (SC)
Military Noninterpersonal trauma, 31. See also Trauma
cognitive processing therapy and, 217–218 exposure
effectiveness of psychological treatments and, 181 Nonsuicidal self-injury, 198–199, 200, 219–221, 369
554 Subject Index

Non-trauma-focused interventions delivery of, 278–283

cognitive processing therapy and, 268 depression and, 419–420
cost-effectiveness findings and, 500t, 511 dosing, 277, 277t, 279–282, 279t
ISTSS guidelines and, 100–101, 104, 104–106 early interventions and, 137–143, 140t
personalized interventions and, 456 evidence that supports, 274–278, 276t, 277t
See also Early intervention; Interventions future directions, 143, 283–284
Numbing, emotional. See Emotional numbing improving treatment effectiveness and, 524, 528
Nurse-led intensive care recovery program, 100, 112, ISTSS guidelines and, 110, 111, 113, 114
121t novel augmentation strategies, 301–306
overview, 8, 143, 272, 284–285
Observed and experiential integration (OEI), 104, 114 pharmacological agents, 138–139
Obsessive–compulsive disorder (OCD), 37, 268, 301 techniques of, 273–274
Olanzapine, 114 theoretical models and, 272–273
Online training, 471–472. See also Training underlying mechanisms and, 522–523
Oppositional defiant disorder (ODD), 433 See also Combined psychotherapy and medication;
Organizational-level approaches, 479–480 individual medications
Outcomes, 459–461 Phase-based approach to treatment, 403
Overshadowing the Threat of Terrorism (OTT), 401 Phenelzine, 114, 281
Oxytocin, 113, 138 Physical abuse, 73–74, 242. See also Child
maltreatment
Pain, chronic. See Chronic pain Physical assault, 242
Panic attacks, 219–220 Physical exercise, 114, 345, 346t, 351–352. See also
Panic disorder, 420–422 Complementary, alternative, and integrative
Parent Trauma Response Questionnaire, 83 (CAI) approaches
Parenting intervention Physical health problems
complex PTSD in children and, 393, 394t, 397 children and adolescents and, 38–39
cost-effectiveness findings and, 505t cognitive processing therapy and, 268
ISTSS guidelines and, 100, 112, 121t complementary, alternative, and integrative (CAI)
parent–child relationship enhancement, 105, 111, approaches and, 355
394t complex PTSD and, 379
preventative and early interventions for children overview, 22–24
and, 151 See also Chronic pain; Somatic experiencing
Paroxetine Physical violence, 31–32. See also Violence exposure
adverse effects, 282 Pie charts, 265–266
combined psychotherapy and medication and, Play therapy, 505t
298–299 Policy-level approaches, 478–479
dosing, 277t, 279–280, 279t, 281 Positive cognition (PC), 238
evidence that supports, 275 Posttrauma factors, 35
ISTSS guidelines and, 114 Posttraumatic Cognitions Inventory (PTCI), 262
overview, 285 Posttraumatic stress disorder (PTSD) in general
Participatory approach, 482 children and adolescents and, 33–35
Passive therapies, 357–358 course and impact of, 19–20
Pediatric Emotional Distress Scale (PEDS), 79t epidemiology of, 18–19
Pediatric medical trauma, 148 future directions, 528–529
Peritrauma factors, 35 improving treatment effectiveness and,
Peritraumatic Dissociative Experiences Questionnaire 524–527
(PEDQ-C), 83 overview, 3–8, 10–11, 33, 492–493, 518–519
Perpetuating factors, 84–85 traumatic stress reaction and, 519–520
Personality traits, 182, 247 underlying mechanisms, 521–524
Personalized Advantage Index (PAI) approach, 459, Potentially traumatic events (PTEs), 69–71. See also
460 Trauma exposure
Personalized interventions Prazosin, 280–281
adapting therapies for specific populations and Prediction models, 131
environments, 451–453 Predisposing factors. See Risk factors
individualized metrics, 457–459 Preferred belief, 238
modular therapies and, 453–455 Pregnancy, 246–247
multivariable prediction models and, 459–461 Preschool PTSD treatment (PPT), 390, 395
neurobiological findings and, 461–463 Present-centered therapy (PCT)
overview, 451, 463–464 cost-effectiveness findings and, 500t
sequential multiple assignment randomized trial ISTSS guidelines and, 105, 113, 170t
(SMART) design and, 455–456 multivariable prediction models and, 459–460
treatment selection, 456–457 overview, 170
See also individual treatment approaches Prevalence
Pharmacological treatments comorbidity in young people and, 433
adults and, 113, 114 overview, 13, 492–493
adverse effects, 140, 278, 282 subsequent exposures to trauma and, 16–17
children and adolescents and, 110, 111, 385–386, of trauma exposure, 15
404–405, 404t Preventative interventions
comorbidity and, 435–436 adults and, 112
complex PTSD and, 385–386, 404–405, 404t children and adolescents and, 110, 147–164
cost-effectiveness findings and, 497, 499t, 500t, E-mental health interventions and, 315–316,
501t, 504t, 510 325–326
Subject Index 555

future directions, 162–163 techniques of, 171f, 172–175

ISTSS guidelines and, 110, 112, 120–128, 121t, See also Cognitive processing therapy (CPT);
155–156 Cognitive therapy for PTSD (CT-PTSD);
overview, 6, 117–120, 119f Combined psychotherapy and medication; Eye
pharmacological treatment and, 141 movement desensitization and reprocessing
theoretical models and, 148–153 (EMDR) therapy; Prolonged exposure (PE);
See also Early intervention; Treatment individual treatment approaches
interventions; Treatment recommendations; Psychopharmacological treatments. See
Universal interventions; individual treatment Pharmacological treatments
approaches Psychosis and psychotic disorders, 181, 198–199,
Primary Care PTSD Screen (PC-PTSD), 60 426–429
Primary care settings, 71–72, 74, 202, 478–479 PTSD Checklist (PCL), 51, 59–60, 219–220
Prognostic variables, 458–459 PTSD Coach, 318f, 319, 328t, 329t
Progress monitoring, 219–220 PTSD Symptom Scale (PSS), 60
Progressive muscle relaxation techniques, 432–433.
See also Relaxation training Quality of life, 260, 494–496
Prolonged exposure for adolescents (PE-A), 397–398 Quality-adjusted life year (QALY), 494–496
Prolonged exposure (PE) Questionnaires, 74–83, 79t, 80t, 82t. See also
cognitive processing therapy and, 214 Assessment; Screening
cognitive therapy for PTSD and, 260 Quetiapine, 142, 275, 277t, 280–281
complex PTSD and, 375–376, 397–398
core elements of, 176–179 Racial/ethnic differences, 15–16, 19. See also Cultural
cost-effectiveness findings and, 497, 499t, 501t, factors
503t, 505t, 512 Rapid eye movement desensitization (REM-D), 104,
delivery of, 194–201 114, 170t
evidence that supports, 192–194 Rapid eye movement (REM), 235
future directions, 201–202 Rapport building, 236–237, 378–379, 389
ISTSS guidelines and, 103, 170t Reactivity, 369, 392
multivariable prediction models and, 459–460 Readiness, client, 237, 260–261, 354
overview, 6, 171f, 174–175, 183–184, 188, 202–203, RealConsent, 316, 326
521 Reassurance, 112, 121t, 170t
personalized interventions and, 458–459 Reclaiming your life strategy, 396
substance use disorders and, 425 Reconsolidation of traumatic memories (RTM), 103,
techniques of, 190–192 113, 170t, 180
theoretical foundations of, 188–190 Recovery, 34, 118–120, 119f, 523
training and, 472 Reevaluation, 240–241
treatment selection and, 457 Reexperiencing, 173, 266–267, 423
See also Exposure techniques; Psychological Refugees, 181, 242
treatment Reintegration, 368
Prolonged grief disorder, 33, 36. See also Grief Relapse prevention, 213–214, 397
Propranolol, 110, 113, 306, 404t Relapse prevention therapy (RPT), 375
Psychodynamic therapy, 105, 114 Relaxation therapy (RT), 194
Psychoeducation Relaxation training
children and adolescents and, 388–389, 392, 394t, cognitive-behavioral therapy with a trauma focus
396 and, 125
chronic pain and, 432–433 cost-effectiveness findings and, 502t
cognitive processing therapy and, 212 ISTSS guidelines and, 114, 170t
cognitive-behavioral therapy with a trauma focus progressive muscle relaxation techniques, 432–433
and, 125 prolonged exposure and, 175, 192
complex PTSD and, 367, 388–389, 392, 394t, 396 See also Breathing training
cost-effectiveness findings and, 498t, 501t, 502t Residential therapy, 269
E-mental health interventions and, 317–318 Resilience, 34, 118–120, 119f
eye movement desensitization and reprocessing Resource development and installation (RDI), 237,
therapy and, 173–174 244
ISTSS guidelines and, 100, 105, 110, 111, 112, 114, Retention, 424–425
121t, 155–156, 156, 170t Revictimization, 16–17, 32–33, 38, 70
mindfulness-based stress reduction and, 347 Risk factors
preventative and early interventions for children children and adolescents and, 34–35, 84, 85,
and, 149, 151, 154, 155–156, 156 399–400
prolonged exposure and, 174–175, 192 complex PTSD and, 399–400
See also Self-directed psychoeducation overview, 23–24
Psychological debriefing. See Debriefing preventative and early interventions for children
Psychological first aid (PFA), 122–123, 150 and, 147–148
Psychological treatment psychotic disorders and, 427–428
adults and, 113–114 of PTSD, 19, 69–71
children and adolescents and, 110–111 subsequent exposures to trauma and, 16–17
core elements of, 176–181 substance use disorders and, 423
effectiveness of, 181–183 for trauma exposure, 15–18
improving treatment effectiveness and, 524–527 underlying mechanisms and, 523
ISTSS guidelines and, 110–111, 113–114 violence exposure and, 32
mechanisms of, 179 Risperidone, 280–281
overview, 169–172, 170t, 171f, 183–184 Routine screenings, 71–74, 85. See also Screening
556 Subject Index

Safety behaviors, 263 Sexual abuse

Saikokeishikankyoto cognitive processing therapy and, 215
evidence that supports, 346t, 350 combined psychotherapy and medication and,
ISTSS guidelines and, 105, 114 301–302
overview, 284, 345 confidentiality concerns in screening and, 73–74
See also Complementary, alternative, and eye movement desensitization and reprocessing
integrative (CAI) approaches therapy and, 237–238, 242
Schizophrenia-spectrum disorders, 426–429. See also See also Child maltreatment; Childhood sexual
Psychosis and psychotic disorders abuse; Sexual violence
School functioning, 16, 39 Sexual orientation, 16
School-based interventions, 151–152, 159, 399–402 Sexual violence
Screening combined psychotherapy and medication and,
children and adolescents and, 70–74 301–302
early interventions and, 131 eye movement desensitization and reprocessing
instruments for, 60–61, 74–83, 79t, 80t, 82t therapy and, 242
overview, 59–62, 70 overview, 31–32
preventative and early interventions for children revictimization and, 38
and, 162 See also Childhood sexual abuse; Violence exposure
See also Assessment Shame, 214, 237–238, 259
Screening Tool for Early Predictors of PTSD (STEPP), Short PTSD Rating Interview (SPRINT), 126, 297
78 Single-session interventions, 112, 122, 170t. See also
SecondLife platform, 472 Brief interventions
Sedative antidepressants, 142, 283 Site visit, 258, 396–397
Seizure disorders, 246–247 Skills Training in Affective and Interpersonal
Selective interventions, 123–124 Regulation for Adolescents (STAIR-A), 402,
Selective serotonin reuptake inhibitors (SSRIs) 403–404
combined psychotherapy and medication and, Skills Training in Affective and Interpersonal
308–309 Regulation (STAIR)
complex PTSD in young people and, 405 complex PTSD and, 372–373, 374
cost-effectiveness findings and, 497, 500t, 501t, modular therapies and, 454
504t, 510 multivariable prediction models and, 459–460
dosing, 277t, 279–280, 279t, 281 overview, 180
overview, 138–139, 273 Sleep problems, 142, 282–283
sleep problems and, 283 Social factors, 70, 268, 526
Self-blame, 213, 223 Social phobia, 37
Self-concept, 371 Sociodemographic factors, 19
Self-directed psychoeducation, 110, 151, 154, 155, 156. Socioeconomic status, 32
See also Psychoeducation Socratic dialogue
Self-esteem, 453 cognitive processing therapy and, 212, 224,
Self-guided Internet-based intervention, 101, 112, 265–266
121t complex PTSD in children and, 388–389
Self-help overview, 172, 176
brief interventions and, 129–130 Somatic experiencing, 39, 105, 114, 350–351, 390. See
cognitive therapy for PTSD and, 260 also Chronic pain; Complementary, alternative,
cost-effectiveness findings and, 497, 501t and integrative (CAI) approaches; Physical
E-mental health interventions and, 317 health problems
ISTSS guidelines and, 112, 121t, 170t Somatic therapies, 500t
preventative and early interventions for children SPAN self-report, 60
and, 151 Spring program, 319–320, 328t
Self-injury. See Nonsuicidal self-injury Stabilization interventions, 244
Self-medication theory, 422–423 STAIR narrative therapy for adolescents (SNT-A),
Self-regulation, 371–372 403–404
Semistructured interview assessments, 81 Standardization of interventions, 323
Separation anxiety, 389–390 Stepped preventative care, 110, 154, 157
Separation anxiety disorder (SAD), 37 Stepped-care CBT-T, 105, 111, 394t
Sequencing approach, 127, 373–375 Stepped-care models of TF-CBT, 406
Sequential multiple assignment randomized trial Stepped/collaborative care (SCC)
(SMART) design, 455–456, 463–464 cost-effectiveness findings and, 498t, 506t
Sequential treatment, 425, 453–455 ISTSS guidelines and, 100, 112, 121t
Serotonin and noradrenaline reuptake inhibitors preventative and early interventions for children
(SNRIs), 273 and, 152
Sertraline Stigma, 323
combined psychotherapy and medication and, 297, Stimulus discrimination, 396. See also Triggers
299–300, 300 Stress management, 268
complex PTSD in young people and, 404t, 405 Stressors, 379–380
cost-effectiveness findings and, 499t Stress-reactive somatic complaints, 390
dosing, 277t, 279–280, 279t, 281 Structured interview assessments, 81, 82t, 121t
evidence that supports, 275 Structured Psychotherapy for Adolescents Responding
ISTSS guidelines and, 111, 114 to Chronic Stress (SPARCS), 402
overview, 285 Structured writing therapy (SWT), 100, 112–113,
Sex/gender differences, 32 126–127
Subject Index 557

Subjective Units of Distress Scale (SUDS), 174, 238, Therapists. See Clinicians
239, 240, 245, 259 Thinking about Recovery Scale, 83
Substance misuse Thoughts, trauma-related, 176–177
children and adolescents and, 84 Threat, 255–257, 256f, 263, 264–265. See also
cognitive processing therapy and, 219–220, 221 Appraisals
combined psychotherapy and medication and, 300 Three-factor model, 34
complex PTSD and, 375–376 Tiagabine, 114
effectiveness of psychological treatments and, 181 “TICES” log, 240
prolonged exposure and, 198–199, 200 Topiramate, 114, 282
See also Substance use disorders (SUDs) Training
Substance use disorders (SUDs) cognitive processing therapy and, 224–225, 269
case example, 22–23 cognitive therapy for PTSD and, 263
cognitive processing therapy and, 221, 268 consultation and, 472–473
comorbidity and, 422–426, 433 didactic training components, 470–472
complex PTSD and, 375–376 E-mental health interventions and, 332–333
overview, 21, 22 large-scale training efforts, 474–476
prolonged exposure and, 200 in low-resource countries, 473–474
See also Substance misuse overview, 469–476, 482–483
Suicidality See also Clinicians
cognitive processing therapy and, 219–221 Training in Psychotherapy (TIP) tool, 470
complex PTSD and, 369 Transcendental meditation (TM), 347, 348. See also
effectiveness of psychological treatments and, 181 Meditation
overview, 22 Transcranial magnetic stimulation (TMS), 106, 114,
prolonged exposure and, 198–199, 200 217, 284, 462
substance use disorders and, 423–424 Transdiagnostic interventions, 8, 434–436, 524
Supported psychoeducational intervention, 100, 112, Trauma Adaptive Recovery Group Education and
121t Therapy for Adolescents (TARGET-A), 402
Supportive/nondirective counseling (SC), 100, Trauma Affect Regulation: Guide for Education and
105–106, 113, 114, 121t, 170t, 394t, 505t Therapy (TARGET), 372–373
Supra-individual contexts, 58–59. See also Contextual Trauma Event Screening Instrument for Children
factors (TESI-C), 76
Surveys, 259, 265–266 Trauma exposure
Survivor to Thriver program, 320, 328t borderline personality disorder and, 429–430
Symptoms case example, 17–18
children and adolescents and, 83 children and adolescents and, 75–76, 85
cognitive processing therapy and, 219–220, chronic pain and, 432–433
267–268 comorbidity in young people and, 433
combined psychotherapy and medication and, consequences of, 33–39
296–297, 301–303 defining traumatic events and, 14–15
comorbidity and transdiagnostics and, 8 epidemiology and, 14, 18–19
complementary, alternative, and integrative (CAI) future directions, 528–529
approaches and, 344, 353–354 natural recovery following, 17–18
complex PTSD and, 55–57, 366–367, 368–369, overview, 13, 23–24, 30–33
370–373 prevalence of, 15
cross-cultural and supra-individual contexts and, risk factors for, 15–18
58–59 screening and, 70–74, 75–76
depression and, 419–420 subsequent exposures to trauma and, 16–17, 32–33
diagnosis and, 33–34, 49–51, 54–55 symptom trajectory following, 118–120, 119f
effectiveness of psychological treatments and, 181–182 traumatic stress reaction and, 519–520
eye movement desensitization and reprocessing See also Potentially traumatic events (PTEs);
therapy and, 236–237 Violence exposure
improving treatment effectiveness and, 526 Trauma impact, 76–77
natural recovery following trauma exposure and, Trauma memory processing (TMP) therapies, 370,
17–18 374–375, 376–377
panic disorder and, 420–422 Trauma processing therapy, 99, 112, 121t, 421
pharmacological treatment and, 141–142 Trauma Screening Questionnaire (TSQ), 60, 61
trajectory of following trauma, 118–120, 119f Trauma Symptom Checklist for Children (TSCYC),
System-level approaches, 478–479 79t
Trauma TIPS, 124, 315, 326
Tailored interventions, 267–268. See also individual Trauma-focused CBT (TF-CBT)
treatment approaches adapting for specific populations and
Tele-health environments, 453
cognitive processing therapy and, 217 children and adolescents and, 80, 389, 390,
mindfulness-based stress reduction and, 347 394–395, 405, 406, 433–434
prolonged exposure and, 197 comorbidity in young people and, 433–434
telephone-based CBT, 100, 112, 113, 121t complex PTSD in children and adolescents and,
Temper tantrums, 389–390 389, 390, 394–395, 405, 406
TENTS, 123 consultation and, 473
Termination, 213–214 effectiveness of, 182
Therapeutic relationship, 378–379, 380, 389. See also ISTSS guidelines and, 102
Rapport building large-scale training efforts and, 475
558 Subject Index

Trauma-focused CBT (cont.) Triggers

multivariable prediction models and, 461 cognitive processing therapy and, 266–267
overview, 521 cognitive therapy for PTSD and, 173, 256f, 257
screening children and adolescents and, 80 complex PTSD in children and, 396
training and, 474 eye movement desensitization and reprocessing
See also Cognitive-behavioral therapy (CBT) therapy and, 240
Trauma-Focused Coping in Schools, 400 panic attacks and, 420–421
Trauma-focused expressive art therapy, 111 Trust, 237, 366–367, 378–379
Trauma-focused interventions
combined psychotherapy and medication and, UCLA PTSD Reaction Index (UCLA PTSD-RI), 76,
287–288 77, 80, 80t
ISTSS guidelines and, 99–100, 102–104, 112, 121t, 170t UCLA Trauma and Grief Component Therapy for
personalized interventions and, 456 Adolescents Program, 400–401
See also Early intervention; Interventions; individual Undifferentiated CBT with a trauma focus, 180, 260.
treatment approaches See also Cognitive-behavioral therapy with a
Trauma-informed care, 150 trauma focus (CBT-T)
Traumatic brain injury (TBI) Unified Protocol for the Treatment of Emotional
cognitive processing therapy and, 217–218, 222 Disorders (UP), 434–435
eye movement desensitization and reprocessing Universal interventions, 121–123, 141, 148. See also
therapy and, 246–247 Preventative interventions
prolonged exposure and, 199 Updating trauma memories procedure, 264–266,
Traumatic memories 267–268, 396
cognitive processing therapy and, 264–266
cognitive therapy for PTSD and, 256f, 257, 258 Validity of Cognitions (VoC) Scale, 238, 239–240, 245
effectiveness of psychological treatments and, 181 Venlafaxine
eye movement desensitization and reprocessing combined psychotherapy and medication and, 300
therapy and, 234–236, 238–240, 243–244 dosing, 277t, 279–280, 279t, 281
prolonged exposure and, 189–190 evidence that supports, 275
psychological treatment and, 177–178, 179 ISTSS guidelines and, 114
Trazadone, 142 overview, 285
Treatment goals. See Goals of treatment sleep problems and, 283
Treatment interventions Veterans
E-mental health interventions and, 316–321, 318f cognitive processing therapy and, 217–218
improving treatment effectiveness and, 524–527 effectiveness of psychological treatments and, 181
ISTSS guidelines and, 101–106 eye movement desensitization and reprocessing
pharmacological treatment and, 141–142 therapy and, 237–238, 245–246
See also Early intervention; Interventions; large-scale training efforts and, 474–476
Treatment recommendations; individual Video conferencing, 472
treatment approaches Violence exposure, 31–32, 423–424, 433. See also
Treatment planning Sexual violence; Trauma exposure
comorbidity and, 436–438, 437f Virtual reality exposure (VRE), 201, 302, 306, 503t.
complementary, alternative, and integrative (CAI) See also Exposure techniques; Prolonged
approaches and, 355 exposure (PE)
complex PTSD and, 367–368, 377 Virtual reality therapy (VRT)
treatment selection, 456–457 cost-effectiveness findings and, 497, 503t
See also Treatment recommendations ISTSS guidelines and, 103, 113–114, 170t
Treatment recommendations overview, 170, 180
for adolescents and children, 8, 83–85 Volproate, 282
complex PTSD and, 369–370
contextual factors in, 476–481 Warriors Internet Recovery and Education (WIRED),
delivery of to children and adolescents, 157–162 328t
future directions, 528–529 Weight training, 433
implementation and dissemination and, 476–481 Withdrawal, 392
improving treatment effectiveness and, 524–527 Working memory theory, 235
ISTSS guidelines and, 95–97, 98–106 Written emotional disclosure (WED), 103
overview, 6 Written exposure therapy, 113, 170t, 180, 216, 425
underlying mechanisms, 521–524 Written trauma accounts, 212, 226, 264–265, 393,
See also Early intervention; International Society 399
for Traumatic Stress Studies (ISTSS) guidelines;
Interventions; Preventative interventions; Yoga
Treatment interventions; Treatment planning; evidence that supports, 346t, 349–350
individual treatment approaches improving treatment effectiveness and, 524
Treatment settings ISTSS guidelines and, 106, 114
children and adolescents and, 158–160 overview, 345
cognitive processing therapy and, 218–219 See also Complementary, alternative, and
complementary, alternative, and integrative (CAI) integrative (CAI) approaches
approaches and, 355, 356–357 Yohimbine, 305–306
prolonged exposure and, 202 Young Child PTSD Screen (YCPS), 78, 79t