Get Alert
Please Wait... Processing your request... Please Wait.
You must sign in to sign-up for alerts.

Please confirm that your email address is correct, so you can successfully receive this alert.

PTSD: Evidence-Based Psychotherapy and Emerging Treatment Approaches
Cole G. Youngner, B.A.; Maryrose Gerardi, Ph.D.; Barbara O. Rothbaum, Ph.D., ABPP
FOCUS 2013;11:307-314. doi:10.1176/appi.focus.11.3.307
View Author and Article Information

Author Information and CME Disclosure

Cole G. Youngner, B.A., Emory University School of Medicine

Maryrose Gerardi, Ph.D., Emory University School of Medicine

Cole Youngner and Maryrose Gerardi report no competing interests.

Barbara O. Rothbaum, Ph.D., ABPP, Emory University School of Medicine

Dr. Rothbaum reports the following disclosure: Co-owner, Virtually Better, Inc.

Address correspondence to Cole Youngner, B.A., Emory University School of Medicine, 1256 Briarcliff Rd., Atlanta, GA 30306; e-mail: cyoungn@emory.edu


Posttraumatic stress disorder (PTSD) is estimated to affect 6.8% of Americans and 13%−20% of U.S. military personnel deployed to Iraq or Afghanistan. Societal impacts include psychiatric and physical comorbidities, which lead to work impairment and increasing health care costs. While treating PTSD with pharmacotherapy has accumulated some empirical support, the Institute of Medicine rates trauma-focused cognitive behavioral therapy as the only first-level treatment for PTSD. This paper explores the evidence for trauma-focused psychotherapy options including exposure therapy, cognitive processing therapy, eye-movement desensitization and reprocessing, and stress inoculation training. Emerging treatment innovations are examined, including medication-enhanced psychotherapy, virtual reality exposure therapy, psychotherapy delivered via telemedicine, and complementary and alternative medicine-based therapies. Implications and Future Directions: Various forms of trauma-focused cognitive behavioral therapy appear to be equally efficacious. Because many patients fail to respond to these treatments, however, more research on the efficacy of alternative treatment approaches is necessary. While there is already emerging evidence for other forms of psychotherapy and alternative methods for delivering psychotherapy, rigorous studies of complementary and alternative medicine approaches are severely lacking. Research demonstrating efficacy for these different treatment options could make treatment more acceptable, tolerable, and available.

Abstract Teaser
Figures in this Article

Your Session has timed out. Please sign back in to continue.
Sign In Your Session has timed out. Please sign back in to continue.
Sign In to Access Full Content
Sign in via Athens (What is this?)
Athens is a service for single sign-on which enables access to all of an institution's subscriptions on- or off-site.
Not a subscriber?

Subscribe Now/Learn More

PsychiatryOnline subscription options offer access to the DSM-5 library, books, journals, CME, and patient resources. This all-in-one virtual library provides psychiatrists and mental health professionals with key resources for diagnosis, treatment, research, and professional development.

Need more help? PsychiatryOnline Customer Service may be reached by emailing PsychiatryOnline@psych.org or by calling 800-368-5777 (in the U.S.) or 703-907-7322 (outside the U.S.).

Figure 1. Vignette: Treatment of PTSD Through Prolonged Exposure

Figure 2. Vignette: Treatment of PTSD Through Cognitive Processing Therapy


IOM:  Treatment for posttraumatic stress disorder in military and veteran populations .  Washington, D.C.,  National Academies Press, 2012
Forbes  D;  Creamer  M;  Bisson  JI;  Cohen  JA;  Crow  BE;  Foa  EB;  Friedman  MJ;  Keane  TM;  Kudler  HS;  Ursano  RJ:  A guide to guidelines for the treatment of PTSD and related conditions.  J Trauma Stress 2010; 23:537–552
[CrossRef] | [PubMed]
Stein DJ, Ipser JC, Seedat S: Pharmacotherapy for post traumatic stress disorder (PTSD). Cochrane Database of Systematic Reviews 2006; ((1):CD002795.)
Stein  DJ;  Ipser  J;  McAnda  N:  Pharmacotherapy of posttraumatic stress disorder: A review of meta-analyses and treatment guidelines.  CNS Spectrums 2009; 14(1(Supp. 1)):25–31
IOM:  Treatment of posttraumatic stress disorder: an assessment of the evidence .  Washington, DC,  The National Academies Press, 2008
Breslau  N:  The epidemiology of trauma, PTSD, and other posttrauma disorders.  Trauma Violence Abuse 2009; 10:198–210
[CrossRef] | [PubMed]
Kessler  RC;  Berglund  P;  Demler  O;  Jin  R;  Merikangas  KR;  Walters  EE:  Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication.  Arch Gen Psychiatry 2005; 62:593–602. Available at doi: 10.1001/archpsyc.62.6.593
[CrossRef] | [PubMed]
Tanielian  T;  Jaycox  LH:  Invisible wounds of war: Psychological and cognitive injuries, their consequences, and services to assist recovery .  Santa Monica, CA,  RAND Corporation, 2008
Cougle  JR;  Keough  ME;  Riccardi  CJ;  Sachs-Ericsson  N:  Anxiety disorders and suicidality in the National Comorbidity Survey-Replication.  J Psychiatr Res 2009; 43:825–829
[CrossRef] | [PubMed]
Leserman  J;  Drossman  DA;  Li  Z;  Toomey  TC;  Nachman  G;  Glogau  L:  Sexual and physical abuse history in gastroenterology practice: how types of abuse impact health status.  Psychosom Med 1996; 58:4–15
Greenberg  PE;  Sisitsky  T;  Kessler  RC;  Finkelstein  SN;  Berndt  ER;  Davidson  JRT;  Ballenger  JC;  Fyer  AJ:  The economic burden of anxiety disorders in the 1990s.  J Clin Psychiatry 1999; 60:427–435
[CrossRef] | [PubMed]
Miller  SM;  Brody  DS;  Summerton  J:  Styles of coping with threat: implications for health.  J Pers Soc Psychol 1988; 54:142–148
[CrossRef] | [PubMed]
Bradley  R;  Greene  J;  Russ  E;  Dutra  L;  Westen  D:  A multidimensional meta-analysis of psychotherapy for PTSD.  Am J Psychiatry 2005; 162:214–227
[CrossRef] | [PubMed]
Bryant  R:  Psychological interventions for trauma exposure and ptsd, in  Post-traumatic stress disorder . Edited by Stein  DJ;  Friedman  MJ;  Blanco  C.  New York,  John Wiley & Sons, 2011
Chard  KM;  Schuster  JL;  Resick  PA:  Empirically supported psychological treatments: Cognitive processing therapy, in  The Oxford handbook of traumatic stress disorders . Edited by Beck  JG;  Sloan  DM.  New York,  Oxford University Press, 2012, pp 439–448
Foa  EB;  Hembree  EA;  Rothbaum  BO:  Prolonged exposure therapy for ptsd: Emotional processing of traumatic experiences therapist guide .  New York,  Oxford University Press, 2007
Cahill  SP;  Rothbaum  BO;  Resick  PA;  Follette  VM:  Cognitive-behavioral therapy for adults, in  Effective treatments for ptsd: Practice guidelines from the International Society for Traumatic Stress Studies , 2nd ed. Edited by Foa  EB;  Keane  TM;  Friedman  MJ;  Cohen  JA.  New York,  Guilford Press, 2009, pp 139–222
Powers  MB;  Halpern  JM;  Ferenschak  MP;  Gillihan  SJ;  Foa  EB:  A meta-analytic review of prolonged exposure for posttraumatic stress disorder.  Clin Psychol Rev 2010; 30:635–641
[CrossRef] | [PubMed]
Bisson J, Andrew M: Psychological treatment of post-traumatic stress disorder (PTSD). Cochrane Database of Systematic Reviews 2007; doi: 10.001002/14651858.CD14003388.pub14651853
Benish  SG;  Imel  ZE;  Wampold  BE:  The relative efficacy of bona fide psychotherapies for treating post-traumatic stress disorder: a meta-analysis of direct comparisons.  Clin Psychol Rev 2008; 28:746–758
[CrossRef] | [PubMed]
Nayak  N;  Powers  MB;  Foa  EB:  Empirically supported psychological treatments: prolonged exposure (PE), in  The Oxford handbook of traumatic stress disorders . Edited by Beck  JG;  Sloan  DM.  New York,  Oxford University Press, 2012
Resick  PA;  Schnicke  MK:  Cognitive processing for rape victims: A treatment manual .  Newbury Park, CA,  Sage, 1993
Monson  CM;  Schnurr  PP;  Resick  PA;  Friedman  MJ;  Young-Xu  Y;  Stevens  SP:  Cognitive processing therapy for veterans with military-related posttraumatic stress disorder.  J Consult Clin Psychol 2006; 74:898–907
[CrossRef] | [PubMed]
Schulz  PM;  Resick  PA;  Huber  LC;  Griffin  MG:  The effectiveness of cognitive processing therapy for ptsd with refugees in a community setting.  Cognit Behav Pract 2006; 13:322–331
Spates  CR;  Rubin  S:  Empirically supported psychological treatments: EMDR, in  The Oxford handbook of traumatic stress disorders . Edited by Beck  JG;  Sloan  DM.  New York,  Oxford University Press, 2012
Brom  D;  Kleber  RJ;  Defares  PB:  Brief psychotherapy for posttraumatic stress disorders.  J Consult Clin Psychol 1989; 57:607–612
[CrossRef] | [PubMed]
Kearns  MC;  Rothbaum  BO:  Promising psychological treatments, in  The Oxford handbook of traumatic stress disorders . Edited by Beck  JG;  Sloan  DM.  New York,  Oxford University Press, 2012
Rothbaum  BO;  Cahill  SP;  Foa  EB;  Davidson  JRT;  Compton  J;  Connor  KM;  Astin  MC;  Hahn  CG:  Augmentation of sertraline with prolonged exposure in the treatment of posttraumatic stress disorder.  J Trauma Stress 2006; 19:625–638
[CrossRef] | [PubMed]
Simon  NM;  Connor  KM;  Lang  AJ;  Rauch  S;  Krulewicz  S;  LeBeau  RT;  Davidson  JR;  Stein  MB;  Otto  MW;  Foa  EB;  Pollack  MH:  Paroxetine CR augmentation for posttraumatic stress disorder refractory to prolonged exposure therapy.  J Clin Psychiatry 2008; 69:400–405
[CrossRef] | [PubMed]
Schneier  FR;  Neria  Y;  Pavlicova  M;  Hembree  E;  Suh  EJ;  Amsel  L;  Marshall  RD:  Combined prolonged exposure therapy and paroxetine for PTSD related to the World Trade Center attack: a randomized controlled trial.  Am J Psychiatry 2012; 169:80–88
Burton  MS;  Youngner  CG;  McCarthy  AJ;  Rothbaum  AO;  Rothbaum  BO:  Enhancing exposure therapy for PTSD using d-cycloserine, in  Future Directions in PTSD: Prevention, Diagnosis and Treatment . Edited by Safir  M;  Wallach  H;  Rizzo  S.  Springer (in press)
Henn-Haase C, Best S, Metzler TJ, Gardner J, Herbst E, McCaslin S et al: Exposure based CBT therapy and D- cycloserine treatment for PTSD in veterans and civilians. Presented at the International Society for Traumatic Stress Studies 26th annual meeting, Montreal, Canada, Nov 4-6, 2010
de Kleine  RA;  Hendriks  G-J;  Kusters  WJC;  Broekman  TG;  van Minnen  A:  A randomized placebo-controlled trial of D-cycloserine to enhance exposure therapy for posttraumatic stress disorder.  Biol Psychiatry 2012; 71:962–968
[CrossRef] | [PubMed]
Litz  BT;  Salters-Pedneault  K;  Steenkamp  MM;  Hermos  JA;  Bryant  RA;  Otto  MW;  Hofmann  SG:  A randomized placebo-controlled trial of D-cycloserine and exposure therapy for posttraumatic stress disorder.  J Psychiatr Res 2012; 46:1184–1190
[CrossRef] | [PubMed]
Dunlop  BW;  Mansson  E;  Gerardi  M:  Pharmacological innovations for posttraumatic stress disorder and medication- enhanced psychotherapy.  Curr Pharm Des 2012; 18:5645–5658
[CrossRef] | [PubMed]
Mithoefer  MC;  Wagner  MT;  Mithoefer  AT;  Jerome  L;  Doblin  R:  The safety and efficacy of +/-3,4-methylenedioxymethamphetamine-assisted psychotherapy in subjects with chronic, treatment-resistant posttraumatic stress disorder: the first randomized controlled pilot study.  J Psychopharmacol 2011; 25:439–452. Available at doi: 10.1177/0269881110378371
[CrossRef] | [PubMed]
Oehen  P;  Traber  R;  Widmer  V;  Schnyder  U:  A randomized, controlled pilot study of MDMA (± 3,4-Methylenedioxymethamphetamine)-assisted psychotherapy for treatment of resistant, chronic Post-Traumatic Stress Disorder (PTSD).  J Psychopharmacol 2013; 27:40–52
[CrossRef] | [PubMed]
Monson  CM;  Fredman  SJ;  Macdonald  A;  Pukay-Martin  ND;  Resick  PA;  Schnurr  PP:  Effect of cognitive-behavioral couple therapy for PTSD: a randomized controlled trial.  JAMA 2012; 308:700–709
[CrossRef] | [PubMed]
Schnurr  PP;  Friedman  MJ;  Foy  DW;  Shea  MT;  Hsieh  FY;  Lavori  PW;  Glynn  SM;  Wattenberg  M;  Bernardy  NC:  Randomized trial of trauma-focused group therapy for posttraumatic stress disorder: results from a department of veterans affairs cooperative study.  Arch Gen Psychiatry 2003; 60:481–489
[CrossRef] | [PubMed]
Cukor  J;  Spitalnick  J;  Difede  J;  Rizzo  A;  Rothbaum  BO:  Emerging treatments for PTSD.  Clin Psychol Rev 2009; 29:715–726
[CrossRef] | [PubMed]
Difede  J;  Cukor  J;  Jayasinghe  N;  Patt  I;  Jedel  S;  Spielman  L;  Giosan  C;  Hoffman  HG:  Virtual reality exposure therapy for the treatment of posttraumatic stress disorder following September 11, 2001.  J Clin Psychiatry 2007; 68:1639–1647
[CrossRef] | [PubMed]
Frueh  BC;  Monnier  J;  Yim  E;  Grubaugh  AL;  Hamner  MB;  Knapp  RG:  A randomized trial of telepsychiatry for post-traumatic stress disorder.  J Telemed Telecare 2007; 13:142–147
[CrossRef] | [PubMed]
Tuerk  PW;  Yoder  M;  Ruggiero  KJ;  Gros  DF;  Acierno  R:  A pilot study of prolonged exposure therapy for posttraumatic stress disorder delivered via telehealth technology.  J Trauma Stress 2010; 23:116–123
Gros  DF;  Yoder  M;  Tuerk  PW;  Lozano  BE;  Acierno  R:  Exposure therapy for PTSD delivered to veterans via telehealth: predictors of treatment completion and outcome and comparison to treatment delivered in person.  Behav Ther 2011; 42:276–283
[CrossRef] | [PubMed]
Morland  LA;  Hynes  AK;  Mackintosh  MA;  Resick  PA;  Chard  KM:  Group cognitive processing therapy delivered to veterans via telehealth: a pilot cohort.  J Trauma Stress 2011; 24:465–469
[CrossRef] | [PubMed]
Strauss JL, Coeytaux R, McDuffie J, Nagi A, Williams Jr. JW: Efficacy of complementary and alternative therapies for posttraumatic stress disorder. VA-ESP Project #09-010, 2011
Department of Veterans Affairs: VA to increase mental health care access through 200,000 telemental health consultations in 2012. Retrieved from http://www.va.gov/opa/pressrel/pressrelease.cfm?id=2335, 2012
Goertz  C;  Marriott  BP;  Finch  MD;  Bray  RM;  Williams  TV;  Hourani  LL;  Hadden  LS;  Colleran  HL;  Jonas  WB:  Military report more complementary and alternative medicine use than civilians.  J Altern Complement Med  (Epub ahead of print: Jan 16, 2013)
Libby  DJ;  Pilver  CE;  Desai  R:  Complementary and alternative medicine in VA specialized PTSD treatment programs.  Psychiatr Serv 2012; 63:1134–1136
[CrossRef] | [PubMed]
Strauss  JL;  Lang  AJ:  Complementary and alternative treatments for PTSD.  PTSD Research Quarterly 2012; 23:1–7
References Container

CME Activity

Add a subscription to complete this activity and earn CME credit.
Sample questions:
Which medication has FDA approval for treatment of PTSD?

See Friedman: PTSD Pharmacotherapeutic Approaches, p 315–320
Which anticonvulsant has shown promise for PTSD treatment?

See Friedman: Anticonvulsant/antikindling agents, p 317
Which medication is recommended as an adjunctive treatment for partial responders to first-line treatments?

See Friedman: Antidepressants; Antiadrenergic Agents; Gabaergic Agonists; Atypical Antipsychotic Medications, p 316–318
Submit a Comments
Please read the other comments before you post yours. Contributors must reveal any conflict of interest.
Comments are moderated and will appear on the site at the discertion of APA editorial staff.

* = Required Field
(if multiple authors, separate names by comma)
Example: John Doe

Related Content
The American Psychiatric Publishing Textbook of Psychiatry, 5th Edition > Chapter 12.  >
Dulcan's Textbook of Child and Adolescent Psychiatry > Chapter 22.  >
Dulcan's Textbook of Child and Adolescent Psychiatry > Chapter 22.  >
The American Psychiatric Publishing Textbook of Psychiatry, 5th Edition > Chapter 12.  >
Textbook of Psychotherapeutic Treatments > Chapter 8.  >
Topic Collections
Psychiatric News
APA Guidelines
PubMed Articles