The American Psychological Association (APA) has established a set of trauma-informed guidelines for the treatment of patients with PTSD, focusing on each person’s dignity and need for personalized treatment (APA, 2024).

4.1 Medications

Current treatments are typically pharmaceuticals along with one or more forms of Cognitive Behavioral Therapy (CBT). A study of 186,240 VA patients with PTSD found that 80.1% had been prescribed psychiatric medications. Pharmaceuticals can target symptoms, such as depression, anxiety, insomnia, and nightmares (Orme-Johnson et al., 2024).

There are very few FDA-approved drugs for treating PTSD. The Veterans Health Administration follows recommendations put forth by the APA. Medications prescribed for PTSD act upon neurotransmitters affecting the fear and anxiety circuitry of the brain including serotonin, norepinephrine, gamma-aminobutyric acid (GABA), the excitatory amino acid glutamate and dopamine, among others (Holzheimer and Montaño, 2024).

Evidence for PTSD pharmacology is strongest for specific selective serotonin reuptake inhibitors (SSRIs)—sertraline (Zoloft) and paroxetine (Paxil)—and a particular serotonin norepinephrine reuptake inhibitor (SNRI), venlafaxine (Effexor). Currently, only sertraline and paroxetine are approved by the FDA for PTSD. From the FDA perspective, all other medication uses are off label (Holzheimer and Montaño, 2024).

Serotonin plays a role in learning, memory, and happiness, as well as regulating body temperature, sleep, sexual behavior, and hunger. Insufficient serotonin is thought to play a role in depression, anxiety, mania, and other health conditions. It is generally recognized that there is no drug or drug cocktail that is specific for or can effectively cure PTSD (Orme-Johnson et al., 2024).

4.2 Trauma-Focused Psychotherapy

The most frequently studied psychotherapies for military-related PTSD are Cognitive Processing Therapy (CPT) and Prolonged Exposure (PE). A number of studies looking at “real world” effectiveness have shown that many veterans find the “best” treatments intolerably uncomfortable, with completion rates of 10% or less. Moreover, about half of the veterans with PTSD do not seek treatment. Of the half that do seek treatment, only half of them get “minimally adequate” treatment (Orme-Johnson et al., 2024).

The Department of Veterans Affairs Defense Clinical Practice Guideline (CPG) for Posttraumatic Stress Disorder, as well as other clinical practice guidelines for the treatment of PTSD, recommend three trauma-focused psychotherapies, Prolonged Exposure (PE), Cognitive Processing Therapy (CPT) and Eye Movement Desensitization and Reprocessing (EMDR), as the most effective treatments for PTSD (NCPTSD, 2023, October 18).

These types of cognitive therapies have for many years been the psychological treatments with the strongest evidence base for PTSD. Trauma-focused cognitive behavioral therapy (CBT) draws from other CBT theories, such as prolonged exposure and cognitive processing therapy. Several studies have shown cognitive behavioral therapies are an effective intervention, leading to improvements in depression, anxiety, emotional dysregulation, interpersonal problems, and risky behaviors (e.g., days of alcohol use) (Han et al., 2021).

The limitations in effectiveness and tolerability of the most frequently employed PTSD treatments all too often leave patients in an unsatisfactory position of fending for themselves. Many patients cannot tolerate reliving their traumatic experiences and simply refuse to participate in trauma-focused therapy. Moreover, patients may be limited by access to a therapist who has been trained in trauma-focused therapy, even if they are willing to undergo it, as well as by cost and/or insurance coverage (Orme-Johnson et al., 2024).

4.2.1 Prolonged Exposure

Prolonged exposure (PE), developed from Emotional Processing Theory, is one of the most strongly recommended treatments for treatment of PTSD. PE works to modify the fear/emotion structure through safe exposure and habituation to the feared stimulus. This can simply consist of thinking about the traumatizing memory until the distress diminishes. Exposure to the stimulus allows a client to learn that:

1. Memories and reminders of the trauma are not dangerous and can be experienced without significant distress.
2. Distress does not last forever.
3. Emotional responses gradually reduce with time.
4. Responses (such as racing heart) are not dangerous.
5. Negative responses can be safely handled.

Recovery from PTSD occurs as the fear/emotion structure is modified in such a way that stimuli no longer elicit extreme negative responses or meanings (McSweeney et al., 2024).

4.2.2 Cognitive Processing Therapy

Cognitive Processing Therapy (CPT) is an evidence-based treatment for PTSD. It places cognitive demands on patients who often suffer from cognitive impairment such as recalling, making sense of new information, and making and executing plans (Cenkner et al., 2021).

As a trauma-focused treatment, CPT is a structured, 12-session protocol that guides patients through the process of thinking and talking about their trauma-related beliefs and emotions. Patients are encouraged not to avoid painful memories and to complete daily practice assignments, which are often written (LoSavio et al., 2024).

For this reason and others, such as concerns about CPT’s effectiveness for patients with moral injury, many clinicians do not provide CPT. The treatment also does not lend itself to personalization. Ongoing research strives to establish ways that clinicians can offer CPT therapy to a population ranging across cultures, cognitive abilities, and levels of literacy (LoSavio et al., 2024).

4.2.3 EMDR

Eye Movement Desensitization and Reprocessing (EMDR) is recommended by the Veteran’s Administration and national health agencies in Australia and the United Kingdom and conditionally recommended by the American Psychological Association. It is a structured form of psychotherapy that was developed in the 1980s by psychologist Francine Shapiro. It focuses on the traumatizing memory, how it is stored in the brain, and how to stimulate bilateral brain activity to encourage resolution of the troubling event.

Many patients are stuck replaying their trauma over and over again. With EMDR, therapists work with their patients to bring back a memory and add new information about what has happened since the event, so they can come to realize they are not to blame or that they are safe now (APA, 2023). This allows the memory to become integrated into the patient’s larger memory system and reduce PTSD symptoms. The treatment is typically administered weekly, in 90-minute sessions over the course of about three months (Beauvais et al., 2023).

4.3 Meditation Techniques

The first study to use a meditation to treat PTSD was conducted at the Veterans Outreach Program in 1985. Although the study enrolled only a small number of patients, the effects were strong for a broad array of outcomes (PTSD symptoms, anxiety, depression, drug and alcohol use, job and family life) (Orme-Johnson et al., 2024).

The next major step in the use of meditation as a medical treatment was in 1979 when Jon Kabat-Zinn began teaching Mindfulness-Based Stress Reduction (MBSR) at the University of Massachusetts Medical School. He created a standardized protocol, initially for the treatment of for chronic pain (Orme-Johnson et al., 2024).

In 2014, the Department of Veterans Services began a Meditation for PTSD Demonstration Project. The goal was to assess the effectiveness of various meditation techniques in the treatment of PTSD. Research indicated that transcendental meditation (TM) in particular produces effects that are opposite to the fight-or-flight stress response. This physiological state came to be referred to as a restfully alert, hypometabolic, physiologic state, or “restful alertness” (Orme-Johnson et al., 2024).

TM subjects have also been found to exhibit significantly faster recovery from stress, consistent with the finding of rapid recovery from PTSD. An magnetic resonance imaging (MRI) study found that activity in the brainstem, which regulates breath rate, heart rate, and cortisol responses, decreased while frontal-lobe executive blood flow increased, suggesting increased control at a deeper level of awareness during TM (Orme-Johnson et al., 2024).

PTSD is treated often with drugs that increase serotonin to improve mood. Transcendental meditation is associated with increased excretion of the serotonin metabolite 5-hydroxyindoleacetic acid (5-HIAA) and decreased excretion of adrenaline and noradrenaline metabolites. These differences in neurotransmitter metabolism suggest a shift to a lower state of arousal, consistent with a normalizing effect. Such a shift might underlie reduction of the hyperarousal associated that often occurs after beginning meditation practice (Orme-Johnson et al., 2024).