PTSD Treatment: A Multi-Pronged Approach

PTSD

Post-traumatic stress disorder (PTSD) is a term often “thrown around loosely,” says Howard Pratt, doctor of osteopathic medicine (DO) and a psychiatrist at the Community Health of South Florida, who treats PTSD.

In reality, it’s is a condition in which you might develop a variety of symptoms like nightmares, intrusive memories or a tendency to avoid anything that reminds you of a traumatic event you experienced or even heard about. You might get startled easily or even blame yourself for what happened to you or to a friend. “What really makes it difficult is that these are not consistent things that are going on all the time,” says Pratt. Sometimes when people experience these types of symptoms it “comes out of the blue,” because they feel like they’ve already moved on from an event.

The earlier a you get PTSD treatment after an acute event, the better, explains Pratt. That treatment can include talk therapy, antidepressant drugs and complementary therapies like yoga. Antidepressants can cause side effects, and many patients can be treated successfully without them; that’s why Pratt maintains that the “frontline” treatment is usually therapy.

Therapy

Cognitive Behavioral Therapy

Cognitive behavioral therapy (CBT) is a widely accepted therapeutic strategy that encompasses a variety of talk-based techniques. Essentially, Sabina Mauro, doctor of psychiatry (PsyD) and a psychologist who treats patients with PTSD, explains that for patients with PTSD, “CBT targets trauma-related thoughts, emotions and behaviors to help the trauma survivor find more adaptive ways of thinking, feeling and behaving.”

For example, deep breathing can be used to treat physiological reactions to trauma memories. You may learn other mindfulness techniques to help with intrusive memories. You’ll also discuss the beliefs you’ve developed in relation to the trauma and learn to reframe them in healthy ways.

While CBT is known to be effective for many conditions, such as anxiety, depression and PTSD, patients may experience additional anxiety or a resurgence of painful memories. 

Exposure Therapy

First, a therapist will help you develop coping mechanisms like breathing techniques to calm you down when you start feeling anxiety or are panicking. Then, you expose yourself to stimuli that triggers your PTSD — in a safe environment, of course. This could mean recalling details of an event, writing, listening to certain sounds or even participating in virtual reality. You practice using calming techniques to control your responses. Over time, the idea is that experiences will cause you less distress and that if you do experience stress or anxiety, you have mastered techniques to manage it.

EMDR Therapy

Unfortunately, Meaghan Thomas, a patient with PTSD, says, “I know [therapy] can really help others.  For me, I can talk about my trauma until I’m blue in the face. It didn’t help me. I couldn’t talk my way out of PTSD.” After years of talk therapy, a broad term used to encompass many types of interactions with a therapist, including CBT, her symptoms continued. She says eye movement desensitization and reprocessing (EMDR) was the solution for her.

EMDR is a technique that’s thought to help uncover and process repressed beliefs and memories. It’s been touted by celebrities like Prince Harry and actress Jameela Jamil. “Therapists use lights, tapping and sound to mimic REM sleep, which is when the brain processes the events of the day,” says Kimberly Perlin, master of social work, (MSW), who uses EMDR in her practice. “EMDR often helps clients process traumas quickly and get relief from their systems faster.”

EMDR is an option if you’ve already developed self-soothing techniques, like controlled breathing, and have specific experiences, behaviors or thought patterns to process, explains Perlin.

Thomas has been undergoing the treatment for about five years and says, “I’m slowly breaking down my trauma and rewiring pathways in my brain that had gotten stuck.” Since starting the treatment, she cites notable improvements in her quality of life.

Complementary Treatments 

Yoga

A 2018 meta-analysis suggests that there is some evidence that yoga can mitigate PTSD symptoms. Thomas and another patient with PTSD, Paul Marlow, both say that yoga played a big role in their treatment plans. Thomas says she “found [yoga] very calming and healing. . . I find myself doing long stretches and poses when my PTSD flares up and my body feels really tight.” Marlow says it helps ease his mind, though sometimes a lack of confidence in his skills prevented him from practicing when he first started out. He added that other types of exercise, such as long hikes, were also helpful.

Sensory Deprivation Tanks

Sensory deprivation, or float tanks, are dark tanks filled with salt water. Thomas and Marlow both say they found the experience of floating in the dark amid silence helpful in reducing stress. But Marlow warned that occasionally the experience left him focusing even more on his emotions, leaving him depressed. A 2018 study, which scanned the brains of people as they spent time in the tanks, suggested that floating can help temporarily relieve stress, but much more research needs to be done. 

Medication 

Thomas says that despite her initial hesitation amid concerns about addiction and dependence, Xanax, a benzodiazepine antianxiety medication, helped her get through a difficult period, marked by severe panic attacks. At the time, she says, “I would get so physically ill and ramped up that none of the techniques I learned in trauma therapy were accessible when I was in that state. . . [the drug] really helped me cut through that panic, so I could access my other coping tools, and it continues to help me today every few weeks if I find myself overstimulated and overwhelmed.”

While the antianxiety treatment has been helpful for Thomas, Pratt says he doesn’t recommend these drugs for most of his patients except in the immediate aftermath of a trauma. He says that over time, they have the potential to increase anxiety. Instead, if his patients do need drugs, he usually starts with a selective serotonin reuptake inhibitor (SSRI) antidepressant. He adds that, “antidepressants are safe medications, and people benefit a lot from them, especially people suffering from PTSD. But, with PTSD, you’re not going to get answers just from the pill form. It has to be in concert with therapy.”

The treatment needs to be started gradually, says Pratt. Patients begin with a dose that is too low to be effective, then, the dosage is gradually increased. Over four to six weeks, the drug will start to produce its positive effects. Gastrointestinal side effects are common because the drug’s target, serotonin receptors, are even more prevalent in the digestive tract than they are in the brain. Taking the drug with food can help.

Another common side effect, Pratt mentions, is feeling jittery. In that state, you might think you need to lower your dose. He says that, in most cases, jitteriness is a sign that the dose should be increased, not decreased.

He emphasizes that while antidepressants are usually safe, they do come with a black box warning that they can increase the risk of suicide. The risk is the highest in the first few months of treatment.  

Every patient is different. In most cases, Pratt says, he tries to taper patients off the drugs after six to nine months if they’re doing well. Antidepressants should never be stopped cold turkey and should always be controlled by both you and your doctor. If you’re seeing a therapist, you should continue to see him or her while you’re coming off of your medication.

Other possible side effects include:

Dizziness, which can increase risk of falls leading to fractures

Headaches

Sleep disturbances

Seizures

Liver damage

Lowered sexual arousal

Experimental Drugs

Psilocybin

In recent years, researchers have turned to drugs like psilocybin, the active ingredient in magic mushrooms, and lysergic acid diethylamide (LSD) in hopes of treating PTSD and other mood disorders. Paul Marlow, who was diagnosed with PTSD about 18 months ago, has been seeing a therapist, practicing yoga and eating healthier. He also uses micro doses of psilocybin. He says he takes the small doses three to four times per week. The doses aren’t enough to disrupt his life, though there have been times when he “weighed them wrong and took too much.” In those instances, he just stays home and watches TV. Usually, he says, the treatment helps ease his anxiety. As long as he doesn’t take too much, he can work, run errands and function normally. 

MDMA

Another drug in clinical trials for PTSD is 3,4-methylenedioxymethamphetamine (MDMA,) which has received a breakthrough designation from the Food and Drug Administration (FDA). That classification may speed up its approval. Marlow used the drug during a one-time six-hour session under the supervision of his therapist. “The next few days I felt like a new human, everything was possible and nothing was too scary for me to move forward with. It severely cut down my anxieties and they stayed away,” he says. 

In one Phase 3 trial, two-thirds of patients who received three doses of the drug under therapist supervision showed a reduction in symptoms two months later. Only one-third of those who received a placebo saw similar effects. Side effects observed in the study included excessive sweating, nausea, feeling cold and muscle tightness. Another Phase 3 trial is underway, and the FDA could approve the treatment in the next two years.

Planning Your Doctor’s Visit and PTSD Treatment

The Veterans Administration (VA) offers an online, interactive PTSD Treatment Decision Tool that can help you learn about options and prepare you to meet with your provider.

You can find a local therapist through your insurance provider or  Psychology Today’s Find a Therapist tool. There, you can specify if you’re looking for providers who treat PTSD, who are LGBTQ-affirming, who use specific treatments like EMDR or specialize in treating patients of certain ethnicities. You can also explore virtual therapy options like Betterhelp, Talkspace and Cerebral.  

No matter which treatment plan you’ve been prescribed, the most important question to ask your doctor is what is the possible outcome of each treatment. Your own aim in seeking treatment could be to sleep better or feel comfortable going out with friends. Maybe you want to reduce panic attacks or stop getting angry over small things. Your treatment objectives are personal to you. “It’s very important that the psychiatrist and the person [who] they’re treating have the same goal,” says Pratt.

You should also ask your doctor if any other medicines or supplements you’re using will interact with the medication you’re prescribed. 

Lastly, says Pratt, it’s crucial to report any side effects you experience as you start a new PTSD treatment. For example, if your depressive symptoms were actually a result of bipolar disorder, antidepressants can cause a manic phase. “Let’s say in 10 days, the person is not sleeping. They have high energy. They’re talking fast.” Those are signs of a manic phase, says Pratt. “I need that person to come back to me [right away for] a simple medication switch.”


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