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Adult Prevention and Early Treatment for PTSD

Guidelines Summary

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Coming Soon: Child Prevention and Early Treatment for PTSD

Overview

In the field of prevention and early intervention for PTSD, who receives an intervention and when is just as important as the intervention itself. ISTSS published its most recent Posttraumatic Stress Disorder Prevention and Treatment Guidelines in 2018 to assist clinicians who provide prevention and treatment interventions for children and adults with or at risk of developing PTSD and Complex PTSD.

Adult-Prevention-Early-Intervention-graph-1.pngIn 2020, Effective Treatments for PTSD (Third Edition) was published to provide a comprehensive review of the clinical research literature and the ISTSS PTSD Prevention and Treatment Guidelines.

These guidelines are organized based on the Institute of Medicine’s classification of prevention, with the addition of early treatment, to provide further clinical insight into who should receive early preventative interventions and early treatment and when they should be administered.

  • Universal interventions target everyone exposed to a traumatic event to intervene before PTSD develops.
  • Selective/indicated interventions target people with higher initial symptoms to prevent the development of PTSD.
  • Early treatment targets people who experience clinically significant PTSD symptoms or have developed early PTSD (within 3 months of traumatic event).
Interventions (e.g., EMDR) reviewed in this fact sheet may be included in more than one category of treatment. Some interventions have been tested for implementation at different levels of the IOM framework.

Universal Preventative Interventions

Post-Trauma Interventions with Trauma-Exposed Individuals

Universal interventions are intended to be delivered to anyone who has been exposed to trauma, regardless of symptoms. Because most people go on to recovery naturally (See the Natural Recovery Fact Sheet) and only 25% develop moderate to severe PTSD symptoms1, universal intervention is unlikely to have a major effect on psychiatric symptoms and can be harmful in some cases. Prevention and early intervention can help facilitate or increase the likelihood of natural recovery.

  • Single-session universal interventions that have been tested to date were found to have Insufficient Evidence to Recommend and should not be used as a part of routine clinical practice. Examples include group and individual debriefing, which involves asking individuals to provide detailed facts of what happened, and their thoughts, reactions and symptoms before providing psychoeducation about symptoms and how to deal with them.
  • Multiple-session universal interventions that have been tested to date were found to have Insufficient Evidence to Recommend as a universal prevention intervention. Examples include brief interpersonal counseling therapy and collaborative care.

Selective/Indicated Preventative Interventions

Post-Trauma Interventions with Symptomatic Individuals

Selective/Indicated interventions target people with higher traumatic stress symptoms shortly after exposure to a traumatic event, because these people have a greater likelihood of developing PTSD. Selective interventions are those that target individuals are at risk of developing PTSD but may not yet be symptomatic. Indicated interventions target those who have detectable symptoms. These interventions should be provided to at-risk populations for greatest treatment efficacy.

  • Single-session selective/indicated interventions show potential for prevention and treatment of PTSD symptoms. Two single-session interventions were determined to be Interventions with Emerging Evidence.
    • Group 512 PIM is an indicated intervention intended to be used for groups that have been exposed to a shared trauma. It is based on debriefing that is supplemented with cohesion training exercises; for example, playing cooperative team games. The cohesion training is intended to be a critical part of the intervention, as cohesion is thought to have protective effects in preventing stress.
    • Single-session Eye Movement Desensitization and Reprocessing (EMDR) follows the EMDR Protocol for Recent Critical Incidents. It is a selective intervention that targets the worst fragment of the trauma memory, followed by the remaining fragments, until all the fragments have been processed.
  • Multiple-session selective/indicated interventions show potential for prevention and treatment of PTSD symptoms. Two multiple-session interventions were determined to be Interventions with Emerging Evidence.
    • Brief dyadic therapy is a selective intervention delivered to a trauma survivor and significant other. It aims to target the social support process following trauma exposure and involves elements of psychoeducation and motivational interviewing, aiming to enhance healthy emotional processing.
    • Trauma TIPS is a selective Internet-based self-guided intervention based on CBT principles of psychoeducation, stress/relaxation techniques, and in vivo exposure. In clinical trials, it was most effective for people with severe initial PTSD symptoms.

Although there is promising evidence for single- and multiple-session selective/indicated interventions, further evidence is needed to support their efficacy to prevent PTSD. 

Early Treatment Interventions

Post-Trauma Interventions with Individuals with Emerging Traumatic Stress Symptoms

Early treatment interventions target people who experience clinically significant PTSD symptoms or are provided shortly after an individual has developed PTSD (within three months of trauma exposure). Nearly all early treatments are multiple-session interventions; thus, this section is organized by level of supporting evidence.

  • Early Treatment Interventions with Standard Recommendations
    • Cognitive-Behavioral Therapy with a Trauma Focus includes all treatments that use standard CBT principles together with trauma processing. This may include relaxation training, psychoeducation, therapeutic exposure or cognitive restructuring.
    • Cognitive Therapy uses techniques to identify and challenge negative automatic thoughts and modify underlying cognitive schemas with less emphasis on exposure to traumatic memories.
    • Brief EMDR Therapy typically includes focusing on fragments of the trauma memory while simultaneously engaging in dual-attention stimulation using eye movements.
  • Early Treatment Interventions with Low Effect
    • A Stepped and Collaborative Care Model has primarily been tested among injured patients. It includes integrated care and provision of flexible interventions based on identified need. Intervention is normally CBT-based, but may also include other psychological approaches (e.g. motivational interviewing), components of case management, and psychopharmacotherapy.
  • Early Treatment Interventions with Emerging Evidence
    • Internet-Based Self-Help is a 10-week CBT-based self-help program consisting of psychoeducation and introduction of adaptive coping strategies.
    • Structured Writing encompasses interventions that rely exclusively on guided writing assignments about the trauma experience that function like a form of exposure.
  • Early Treatment Interventions with Insufficient Evidence to Recommend
    • Behavioral activation, brief CPT, internet virtual reality therapy, nurse-led psychological intervention, supportive counseling and telephone-based CBT-T were found to have insufficient evidence to recommend for the early treatment of PTSD among adults.

Early Pharmacological Intervention

Early pharmacological intervention includes prescription of medication in adults within the first three months of exposure to a traumatic event to reduce adrenergic activity to reduce noradrenaline release.
  • Early Universal Pharmacological Interventions with Emerging Evidence
    • Hydrocortisone prescribed within the first three months could be considered as a preventative intervention for people with severe physical illness or injury, shortly after a traumatic event.
  • Early Pharmacological Treatment Interventions with Insufficient Evidence
    • Docosahexaenoic acid, escitalopram, gabapentin, oxytocin and propranolol within the first three months of a traumatic event have insufficient evidence for the prevention or treatment of PTSD symptoms among adults. 

Summary

  • Because most people will recover naturally following trauma exposure, universal prevention strategies have largely been found to have insufficient evidence to recommend and in some cases, may actually be harmful.
  • Current evidence suggests it is important to target interventions to the population at risk with higher symptoms for greatest treatment efficacy, given that these people are most likely to develop PTSD.1
  • Research suggests that selective/indicated interventions focusing on social support, skill building, cognitive restructuring, and therapeutic exposure may be most effective for those who are at risk for PTSD or demonstrating early symptoms, but do not yet meet criteria for a trauma-related disorder. 
  • There is a strong body of literature suggesting the efficacy of CBT with a trauma focus (which typically involves components of CBT and imaginal and graded in vivo exposure), cognitive therapy, and EMDR for those experiencing clinically significant PTSD symptoms or those who have developed early PTSD (within three months of trauma exposure).

ISTSS’ Sources for More Information

  • Effective Treatments for PTSD (Third Edition) provides a comprehensive review the clinical research literature and PTSD practice guidelines in order to assist clinicians who provide prevention and treatment interventions for children, adolescents and adults with or at risk of developing PTSD and Complex PTSD.
  • The Methodology and Recommendations document includes the full recommendations and describes the methodology used to develop them and the position papers.
  • Additional International Clinical Practice Guidelines for treatment of Acute Stress Disorder and PTSD can be found on the ISTSS website.
  • Psychological First Aid (PFA) is a universal approach that has been adopted by the World Health Organization, Red Cross and United Nations. PFA is not a formal therapy but rather an approach to offer practical assistance, promote safety, and foster hope. However, there have not been enough rigorous evaluation of PFA interventions to prove its efficacy or to be included as a formal recommendation in the ISTSS Prevention and Treatment Guidelines. 

References

  1. O’Donnell, M. L., Pacella, B. J., Bryant, R. A., Olff, M., & Forbes, D. (2020) Early Intervention for Trauma-Related Psychopathology. In D. Forbes, J. I. Bison, C. M. Monson, & L. Berliner, Effective Treatments for PTSD: Practice Guidelines from the International Society for Traumatic Stress Studies (pp. 117-131). Guildford Press.
  2. Bisson, Berliner, Cloitre, Forbes, Jensen, Lewis, et al. (2020) ISTSS PTSD Prevention and Treatment Guidelines Recommendations. Effective Treatments for PTSD