Whole Health Library

Todd is a 33-year-old Veteran of Operation Iraqi Freedom (OIF).  He “saw a lot go down” during his time in Iraq, but he felt like he was doing fairly well when he completed his tour and returned to the United States in 2009.  Six months after his return, however, he developed a number of troubling symptoms:

• He began to have flashbacks, focused on when his teammate, Hal, lost his leg in an explosion.
• He finds himself wanting to avoid crowded areas or places where there is a lot of noise. He tells you, “I can’t set foot in a mall, a theater, or some other crowded place like that.”
• He finds it is impossible to trust anyone now, and he hasn’t felt relaxed or happy in years. He gets into fights easily.  He always positions himself in a room so he can see the doors and windows.
• He is haunted by the thought that he should have been the one to lose a leg, not Hal.
• He finds it difficult to maintain romantic relationships or friendships. His concentration is poor, and he is frustrated that he has not done well in college courses he has tried taking.  He says, “Every time I try to do something new, it’s like I sabotage myself.  Or I get all wired and reactive and it makes everything go wrong.”

To cope, Todd drinks, sometimes as much as a case of beer daily, but on good days, he does not drink at all.  He does not own a gun or have plans for harming himself, but it has occurred to him that, as he puts it, “my life has been so hard that I am not so sure I want it anymore.”  He was initially diagnosed with anxiety, until he sought out the advice of a psychiatrist who made the diagnosis of PTSD.  He takes his medications as prescribed by his psychiatrist, and wants to do “anything and everything” he can to improve his quality of life.

Erica is a 34-year-old Veteran of Operation Enduring Freedom (OEF).  During her deployment, she was sexually assaulted.  She did not press charges due to various circumstances, including being threatened by a superior officer when she went to him for help.  Since her return to the United States, Erica has had difficulty in finding work, primarily because she wants to minimize direct interactions with men.  She tells you, “I just can’t stand to be around other people, especially men, because it all takes me back to when I was raped.”  For a year, she worked out of her home.  However, she developed worsening depression and attempted suicide via an overdose of one of her sleep medications in 2012.  In the wake of the suicide attempt, her worsening concentration, sleep problems, and periodic anxiety attacks, she lost her home-based job.  She was evicted and has been homeless for several years.  She currently lives in a women’s shelter.

Melissa is a 52-year-old Veteran of both the Gulf War (Operation Desert Storm) and OIF.  In her role as a medic, she was often one of the first to respond when explosions or other events generated casualties.  While she states she “made it out without a scratch,” she also tells you, “I still feel like something is broken inside me.”  Melissa currently works as an EMT.  She has some good days and some bad days, but it is increasingly difficult for her to go to work due to the fear that she will be a first responder at a serious trauma and end up “losing it to the point where I can’t do my job well.”

Todd, Erica, and Melissa all receive their care at the same VA facility.  Each of them, when given the option, agreed to work with a Whole Health Partner.  Their Whole Health Partner, Richard, who was diagnosed with PTSD himself after serving in Vietnam, met with each of them several times to outline their Mission, Aspiration, Purpose (MAP) and to begin some personal health planning.

These are men whose minds the Dead have ravished.

Memory fingers in their hair of murders

Multitudinous murders they once witnessed.

Wading sloughs of flesh these helpless wander,

Treading blood from lungs that had loved laughter.

—Wilfred Owen, English poet and WWI soldier, 1893-1918

The need for better solutions for PTSD is shown by the immense economic and societal burden that results. The economic cost in the United States among all U.S. civilians, active-duty military personnel, and veterans is staggering at 232.2 billion dollars (data collected in 2018).  Of this, 18% of costs were from military personnel and veterans, who collectively make up about 8% of the U.S. population.  In the civilian population, the economic burden was driven by direct health care ($66.0 billion) and unemployment ($42.7 billion) costs. In the military population, the excess burden was driven by disability ($17.8 billion) and direct health care ($10.1 billion) costs.[149]

PTSD affects 7%-8% of all Americans at some point during their lifetimes, with women being affected twice as often as men (10% versus 5%).[1]  The National Vietnam Veterans Readjustment Study estimated the lifetime prevalence of PTSD for male and female Vietnam Veterans as 31% and 27% respectively.[2]  Prevalence for Gulf War Veterans is about 12%, and for OEF/OIF Veterans, is around 14%.[3,4]  The risk of developing PTSD seems to increase for many Veterans over time after they experience trauma, especially in the first three to six months after return from combat.[5]

The etiology of PTSD is complex and arises out of a complex interaction of biological, psychosocial, and cognitive factors.[6,7]  A considerable amount of research has found that trauma has negative effects on physical health, pain, sleep, relationships and across many other aspects of life. Genetic studies have even shown that people with combat-related PTSD may be genetically predisposed to have more inflammatory dysregulation, and this is likely linked to why people with PTSD have a higher risk of inflammatory disorders.[8]

Diagnosing PTSD

Historically, it was argued by some that PTSD is not an actual diagnosis; however, research indicates that there are a variety of neurological and psychobiological reactions to trauma that occur, many of which are linked to the development of PTSD.[10]

After it is established that a person has experienced trauma, there are four main criteria for a PTSD diagnosis outlined in the Diagnostic and Statistics Manual of Mental Disorders, 5^th edition, Revised (DSM-5-TR).[11,150]  The four general classes of PTSD symptoms include the following:

1. Intrusion symptoms. These can include recurrent, involuntary, or intrusive memories or dreams.  Distress may be triggered by events that have something in common with the traumatic experience(s).  Flashbacks may occur.
2. People with PTSD typically attempt to avoid memories, thoughts, feelings, or external reminders related to traumatic experiences.
3. Cognitive and/or mood disturbances tied to the traumatic event(s). A person may experience impaired memory, exaggerated negative beliefs, inappropriate blame, persistent negative emotions, and other similar symptoms.
4. Hyperarousal and reactivity. This can manifest as irritable behavior, recklessness, hypervigilance, exaggerated startle responses, and sleep problems, among other symptoms.

Symptoms within each category must be present for more than a month for PTSD to be diagnosed.  Otherwise, the diagnosis of Acute Stress Disorder is made instead. 

The gold standard for diagnosing PTSD is a structured clinical interview such as the Clinician-Administered PTSD Scale (CAPS-5).  The CAP-5 is a 30-item structured interview with three versions that can be used to make 1) current (past month) diagnosis of PTSD, 2) lifetime diagnosis of PTSD, and 3) assess PTSD symptoms over the past week.[151]  When necessary, the PCL-5 can be scored to provide a provisional PTSD diagnosis. The PCL-5 is a 20-item questionnaire, corresponding to the DSM-5 symptom criteria for PTSD.  The PCL-5 is a self-report measure that can be completed by patients in a waiting room prior to a session or by participants as part of a research study. It takes approximately 5-10 minutes to complete. Interpretation of the PCL-5 should be made by a clinician.[152]

For more information about diagnosis (useful to both patients and clinicians), or to access further information on assessment measures refer to the National Center for PTSD website.[12]

Risk Factors

Understanding the risk factors for the development of PTSD provides valuable information to assist in early detection and effective treatment engagement, retention and outcomes for Veterans.

According to a 2015 review of 116 studies, the following can be said about risk factors for PTSD in Veterans[9]:

• Risk is higher for younger people; it is higher for males who are under 40 years of age and females under 30.
• Lower level of education correlates with greater risk.
• Black/African American Marines have been noted to have lower risk.
• Not being in a relationship increases risk.
• Being in the Army or the Marines versus other military branches increases chances of developing PTSD.
• Risk is higher for enlisted personnel compared to officers.
• Risk also goes up based on what one does during deployment; it is higher for health care, service and supply, and combat personnel.

In another 2015 analysis, researchers conducted a meta-analysis of data from 32 studies and found that military personnel and veterans were usually more likely to develop PTSD if they had one or more risk factors stemming from before the trauma: female sex, ethnic minority status, low education, non-officer ranks, army service, combat specialization, high numbers of deployments, longer cumulative length of deployments, more adverse life events, prior trauma exposure, and prior psychological problems.[153]  Various aspects of the trauma period also constituted risk factors. These include increased combat exposure, discharging a weapon, witnessing someone being wounded or killed, severe trauma, and deployment-related stressors. Lastly, lack of post-deployment support during the post-trauma period also increased the risk of PTSD.

Women veterans are the fastest growing demographic of veterans who experience disproportionally high rates of PTSD, 13%, compared to 6% of men veterans, and between 11–78% experience chronic pain, compared to 9–50% of men veterans.  Women are more likely to experience military sexual trauma.[154]

PTSD may be more likely in people who have sustained a traumatic brain injury.[155]  An analysis from 2023, which reviewed data from 50 studies found that service members deployed to conflict zones may be at greater risk of developing post-traumatic stress disorder if they were physically, emotionally or sexually abused in childhood.[156]  Loneliness has also been linked to PTSD symptoms in a number of different populations, including Veterans.[157]

Etiology

The Wave 3 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC-III) study found that six out of every 100 adults (or 6%) will have PTSD according to DSM-5 in their lifetime.[158]  Lifetime PTSD prevalence was found to be higher in women (8%) than in men (4%). The past 12-month prevalence was 5% and the lifetime prevalence was higher in women (6%) than in men (3%).

According to the NESARC-III survey, which included over 3,100 Veterans among the total participants, PTSD is slightly more common among Veterans than civilians. At some point in their life, 7 out of every 100 Veterans (or 7%) will have PTSD. PTSD is also more common among female Veterans (13%) versus male Veterans (6%).  Lifetime prevalence also was higher among Veterans younger than 65 (15% ages 18-29, 10% ages 30-44, and 9% ages 45-64) than among Veterans 65 or older (4%). In another nationally representative sample of over 4,000 U.S. Veterans surveyed in 2019-2020, the National Health and Resilience in Veterans Study (NHRVS), past-month prevalence of PTSD according to DSM-5 was 5% overall, and higher among women (11%) than among men (4%).[159]  In the NHVRS sample, for WWII/Korean War, Vietnam War, Persian Gulf War, and OEF/OIF, current prevalence was 2%, 5%, 14% and 15%; lifetime prevalence was 3%, 10%, 21%, and 29% respectively. The estimates are likely affected by differential mortality across cohorts and should be interpreted with caution. 

Why do some people develop PTSD and others do not?  Genetics, the environment, [14] and adverse childhood experiences all can have a profound impact, as can many other factors.[15]  The goal is to stack the odds so as to prevent PTSD from ever even developing, and to focus on healing at all levels if PTSD already has occurred.  

Fight or flight, perhaps the most familiar stress response, is linked to activation of the sympathetic nervous system.  Polyvagal theory may explain some aspects of the development of PTSD by focusing on the vagus nerve, which is linked with the parasympathetic nervous system.  This theory, proposed by Stephen Porges, holds that behavior can be affected differently depending on which part of the vagus nerve is activated.  When the ventral vagus is activated, a person feels safe and tends to build connections with others.  Conversely, when a person (or other animal) feels that their survival is threatened, the dorsal vagus can be activated.  Dorsal vagal activation is associated with withdrawing, even shutting down altogether.  This is linked to the avoidance and withdrawal symptoms so commonly observed in PTSD.

Research also indicates that people with PTSD have significant increases in levels of inflammatory markers, such as interleukins 1β and 6, tumor necrosis factor-α, and C-reactive protein.  It is thought that inflammation is not only an effect of having PTSD, but also a causative factor.[16]  Neuroinflammation, anxiety, and chronic stress may all contribute to PTSD development.[17]

Comorbidities

PTSD is associated with poorer functioning, lower quality of life, and earlier onset of a number of physical and mental health problems.[18].  It is vital to account for these during personal health planning, since they strongly influence overall patient outcomes.[19]  PTSD never exists in a vacuum.  Just as the Whole Health approach and the Circle of Health can help account for each individual’s unique array of PTSD symptoms, it also can help organize the plan with respect to a person’s multiple comorbid conditions.

Veterans with PTSD have more somatic symptoms, health care visits, and work absenteeism.[20]  Of particular concern, is suicide rate. In 2021, the age-adjusted suicide rate of Veteran men was 43.4% greater than that of non-Veteran U.S. adult men, and the age-adjusted suicide rate of Veteran women was 166.1% higher than that of non-Veteran U.S. adult women. [21,161]  In fact, the United States National Comorbidity Study found people with PTSD are six times more likely to attempt suicide than their peers.[22]  The reasons for this are complex, as noted in a recent factsheet published by the National Center for PTSD.  Risk increases if someone has more distressing trauma memories, poorer impulse control, or a tendency toward a higher level of anger than average.  A 2017 study suggested that targeting depression and internal hostility might be particularly beneficial for PTSD patients.  There is a link between suicide and combat guilt, and the risk is greater in combat trauma survivors who were wounded more than once or hospitalized as a result of their injuries.

Suicide risk is significantly higher in people with PTSD for many reasons.  Clinicians should ensure the following numbers are easily accessed by all Veterans and their family/friends:

• Suicide and Crisis Lifeline: 988
• Veterans Crisis Line: 988, then press “1”

Fortunately, a landmark 2013 review by Gradus and colleagues indicated that the reverse is also true; successful treatment of PTSD significantly lowers suicide risk.[23,24]  Researchers are actively exploring which suicide prevention measures are most effective for people with PTSD.[25]

Comorbidity is the rule and not the exception among Veterans with posttraumatic stress disorder.[162]  Fortunately, many problems that co-occur with PTSD often resolve or show improvement when PTSD is successfully treated. Specific comorbidities related to PTSD include the following:[26]

• Sleep disorders. A large body of research has documented the significant association between self-reported sleep disturbances and PTSD, with estimates of up to 63% of those with PTSD.[163-165] In the National Vietnam Veterans Readjustment Study, 52% of combat Veterans with PTSD reported significant nightmares.[163]  These symptoms have a significant impact on quality of life and even overall treatment outcome.[27]  Sleep abnormalities exist in PTSD and Obstructive Sleep Apnea (OSA) has been noted to co-occur with PTSD.[166,167]  A recent cross-sectional study found an association between PTSD and sleep-disordered breathing.[168]
• Suicide Risk. Increased risk of suicide among Veterans with PTSD is well established. It’s related consequences are associated with higher rates of suicidal ideation and suicidal self-directed violence (S-SDV) .[169] Suicide rates among Veterans remain well above the civilian rate. In 2021, the age-adjusted suicide rate of Veteran men was 43.4% greater than that of non-Veteran U.S. adult men, and the age-adjusted suicide rate of Veteran women was 166.1% higher than that of non-Veteran U.S. adult women.[170]  Also noted, Veterans with TBI had suicide rates 56% higher than Veterans without TBI and three times higher than the U.S. adult population.[171]
• Anxiety. Although a Veteran may have had anxiety prior to trauma (such as in generalized anxiety disorder or obsessive compulsive disorder) anxiety is a common psychiatric comorbidity of PTSD.  In one sample of 86 Veterans diagnosed with PTSD, 73.3% had another anxiety disorder diagnosis and within this sample, 39.3% of these veterans had a comorbid generalized anxiety disorder diagnosis, 37.4% had a comorbid panic disorder diagnosis, 22.1% had a comorbid social anxiety disorder diagnosis, and 12.8% had a comorbid obsessive-compulsive diagnosis.[172]  It is also good to keep in mind that what first may seem to be anxiety could actually be part of the hyperarousal symptom cluster that defines PTSD.[20]

 

• Depression is four to seven times more likely in people with PTSD, particularly in women.[28]
• Personality disorders. Examples include borderline, bipolar, and narcissistic personality.[29]   In one outcome study, the presence of a personality disorder was  assessed in 115 male combat veterans with PTSD and depression. Within this sample, 45.2% had one or more personality disorders—most commonly paranoid (17.4%), obsessive-compulsive (16.5%), avoidant (12.2%), and borderline (8.7%)—and 19 (16.5%) had two or more.[173]  Rates were generally highest among Veterans experiencing substance use or elevated suicide risk.[174]  Further research is needed in this area, however.
• Substance use disorders. Alcohol and other substance use disorders are problematic for many people with PTSD.[19]
• Pain disorders. PTSD is a known risk factor for the development of chronic pain (CP) conditions. Almost 1 in 5 individuals with chronic pain fulfills the criteria for PTSD.[175-177]  To start with, symptoms of pain are higher for Veterans in general, when compared to nonveterans. According to CDC data from 2010 - 2014, 65.5% of U.S. military veterans say they are in pain (compared to nonveteran 56.4%), and 9.1 percent say their pain is severe (compared to 6.3 of nonveterans).  For comparison, persistent pain was reported to be present in 20% to 30% of individuals from community and mental health outpatient clinics who had a current PTSD diagnosis.[178]  In Veterans, the reported prevalence of CP in PTSD was much higher. It ranged from 49% to 80% in four studies.[179-182]  The types of pain vary but include back pain, fibromyalgia, chronic musculoskeletal disorders, and osteoarthritis.[30,183]
• Metabolic syndrome. People with PTSD have higher rates of obesity, hypertension, dyslipidemia, diabetes, and vascular disease.[31]  This is thought to be in part due to higher cortisol levels that predispose to inflammation.  PTSD may be considered an independent heart disease risk factor (pooled hazard ratio was 1.55 with 95% CI of 1.34-1.79).[32]
• Impaired immunity. This is associated with increased infections, gastric ulcers (H. pylori infection), and risk of HIV positivity.[29]
• Autoimmune disorders. These include thyroid disease and rheumatoid arthritis, among others. [29] Studies have looked at both active duty military personnel with PTSD and Iraq and Afghanistan Veterans with PTSD.[184,185].  Results suggest that they have an elevated risk of a range of autoimmune diseases, regardless of combat experience or prior trauma, and when compared to Veterans with no psychiatric diagnoses. They had twice the risk of being diagnosed with an autoimmune disorder compared to those without any psychiatric disorders, and 51% increased risk compared to Veterans with psychiatric disorders other than PTSD. Overall, women with PTSD had nearly three times higher prevalence of autoimmune disorders. Military Sexual Trauma (MST) was independently associated with increased risk for autoimmune disorders in both women and men.
• Grief. Grief and traumatic stress are closely connected.  Veterans with PTSD who have unresolved loss from trauma may be limited in their ability to grieve more recent losses, and this can result in challenging emotions or behaviors.  They may experience depression, low self-esteem, isolation, and an increase in nightmares.[33] A study of 114 Vietnam-era combat Veterans admitted to a PTSD inpatient rehabilitation unit identified that 70% scored higher (i.e., worse) on standardized measures of grief symptoms related to friends lost in combat 30 years previous than did spouses who were bereaved in the past six months.[34]  The investigators ultimately concluded that treating the symptoms of unresolved grief may be as important as treating fear-related symptoms of PTSD.
• Traumatic brain injury (TBI). PTSD and TBI share a number of characteristics, including sleep disruption and cognitive impairment.[35] In military populations, the relative frequency of associated PTSD with TBI was 48.2%.  In civilian populations relative frequency of PTSD following TBI was 12.2% (after 3 months), 16.3% after 6 months, 18.6% after 12 months and 11.0% after 24 months.[186]  In military populations, however, both within the restricted range of mild TBI and across a broader range of TBI severities, risk of PTSD increases with the severity of the TBI.[187]  Veterans with TBI had suicide rates 56% higher than Veterans without TBI and three times higher than the U.S. adult population. From 2006–2020, suicide rates increased by 15% per year for Veterans with TBI, 14% per year for Veterans without TBI, and 1% per year for the U.S. adult population.[171]  Veterans who use VA health care must undergo mandatory TBI screening if they served in combat operations.  This is to identify individuals who were exposed to events that increase the risk for TBI and have symptoms that may be related to that specific event or events.

For additional information on PTSD and comorbidities, along with a helpful list of resources related to various comorbid conditions, refer to the National Center for PTSD website.[36]

The symptoms of PTSD seldom exist in isolation.  Always keep comorbidities in mind when working with people with PTSD.  Pain, substance use disorders, affective disorders, autoimmune issues, and sleep problems are among the many comorbidities that may be present.  Each of these, when present, can make the risk of suicide even greater.

The three “Meet the Veterans” narratives at the beginning of this overview offer a snapshot of the varied ways PTSD can present. [37]  A traumatic event can involve an actual or perceived threat to life, personal safety and security, or physical integrity.[11]  It can be directly experienced, witnessed in person, or heard about (in cases of family members or close friends).  As in the case of Melissa, PTSD can arise after witnessing the details of traumatic events being experienced by others. 

Combat trauma, as experienced by Todd, is perhaps the most familiar traumatic precursor to PTSD for most clinicians, but PTSD has different causes— and effects—for each person who suffers with it.  Unfortunately, Erica’s situation of PTSD secondary to military sexual trauma (MST) is not uncommon.  One in six civilian women experience sexual assault, and for military women the frequency climbs to an estimated one in three.[38]  Forty percent of homeless women Veterans report a history of sexual trauma in the military.[39]  Service members who identify as lesbian, gay, or bisexual also face a heightened risk for sexual assault and experienced a higher risk for distress and suicide following a sexual assault.  MST is the main causal factor of PTSD in women, in contrast to combat experience being the strongest predictor in men.[40,41]  Male Veterans (1.1%, versus 21% of women) also experience military sexual trauma.[42]  Risk of suicide markedly increases (hazard ratios of 1.7 and 2.3 for men and women respectively) with a history of MST.[42]

The VHA currently mandates routine screening for PTSD in ambulatory settings and supports access to treatment through comprehensive mental health services, including PTSD specialty teams, primary care-mental health integration programs, and behavioral health interdisciplinary program teams located in many general mental health clinics.  VA policy set forth in the 2023 VA/DoD Clinical Practice Guideline Management of Posttraumatic Stress Disorder and Acute Stress Disorder requires that every Veteran diagnosed with PTSD be offered the full continuum of PTSD care through evidenced-based recovery-oriented, culturally informed and patient-centered services that align with the Veterans’ preferences and values. It offers three evidence-based psychotherapies—Prolonged Exposure,  Cognitive Processing therapies and Eye Movement Desensitization and Reprocessing (EMDR)—when clinically appropriate.  These therapies are discussed in greater detail below.

Education

1. The Veterans Administration/Department of Defense Practice Guideline for the Management of PTSD and Acute Stress Disorder (2023) provides specific suggestions for evidence-based treatment for PTSD.[188-190] The National Center for PTSD provides a wide array of materials and products to assist the Veteran with PTSD.  Educating the patient about what is available to them and their many options, and including them in the decision-making around treatment will encourage involvement and retention in treatment.
2. Inform the patient about evidence-based psychotherapy and/or evidence-based pharmacotherapy, allowing patient and clinician preferences to drive the selection of therapies. As well, educate Veteran about materials and products available on line.
   1. Using the PTSD Treatment Decision Aid with Your Patients
      Learn how to use this online decision aid to help your patients make informed decisions about their PTSD treatment. This tool offers comprehensive information on first-line, evidence-based PTSD treatments identified in the 2023 VA/DoD Clinical Practice Guidelines, including: Cognitive Processing Therapy (CPT), Eye Movement Desensitization and Reprocessing (EMDR), and Prolonged Exposure (PE).
   2. Using AboutFace: Real PTSD Stories. AboutFace is an educational website that explains PTSD using video stories and easy-to-read text from real Veterans, family members and VA treatment providers to help explain the experience of living with PTSD and the benefits of effective PTSD treatment.
      Find out how to use the AboutFace online video gallery with your patients.
3. Support them with self-care. There are a number of excellent educational products developed by the National Center for PTSD for Veterans and their family members.  These include “Understand PTSD” and “Understanding PTSD Treatment,” as well as a broad range of smartphone apps, podcasts  and online courses, and other products. Clinicians can recommend smartphone apps and online tools that allow Veterans to understand and self-monitor symptoms.  These include the following:
   1. Mobile Apps
      PTSD-related mobile applications (apps) provide self-help, education and resources. There are treatment companion apps for people who are in therapy to use with their health care provider to make treatment easier. Includes PTSD Coach Online (self help resource to supplement treatment or reinforce skill development post treatment) and PTSD Family Coach.

 

• Help with PTSD for You and Your Family - CRAFT PTSD
  Community Reinforcement and Family Training (CRAFT) - is a web-based course for family members of Veterans working to manage PTSD. This course teaches family members how to encourage their Veteran to get treatment and support them during care.
• PTSD Bytes podcast
• PTSD Monthly Update

Collaborative treatment planning

A collaborative care approach to therapy administration, including care management, may be considered; however, supportive evidence for this specifically for PTSD is currently lacking.  Evidence suggests that PTSD treatment dropout rates are higher among military than civilian study populations.[191]  A systematic review and meta-analysis found that the pooled rate of dropout from randomized clinical trials of psychological therapies for PTSD was 16% (95% CI 14–18%).[192]  Another systematic review and meta-analysis of 26 randomized controlled trials (RCTs) of military PTSD treatment reported dropout rates ranging from 3% to 46%, with an aggregate dropout rate of 24.2%. The findings from this meta-analysis demonstrated that patients were significantly more likely to drop out of trauma-focused therapy than non–trauma-focused therapy (RR (relative risk) = 1.60, 95% CI [1.29, 1.99] for 12 RCTs). Dropout percentages based on treatment type were 27.1% for trauma‐focused treatments, 16.1% for non–trauma‐focused treatments, and 6.8% for waitlist groups.[193]  Specifically, younger age, concurrent substance use, and service-connected disabilities, practical concerns (e.g., balancing multiple life roles) emerged as factors that consistently contributed to treatment dropout.[194]  The presence of more co-occurring psychiatric disorders was associated with better retention and baseline PTSD severity was not associated with retention.[195]  Given that it is often difficult to convince those with PTSD to seek any form of treatment,[45] it is vital that clinicians carefully match individual Veterans with the therapies and practitioners most appropriate for them.  This can be accomplished through a collaborative process between Veterans with PTSD and their health care teams that includes the following steps:

1. Identify realistic, stepwise functional goals including a list of key activities/domains.
2. Choose specific treatment goals and patient centered indicators of progress that include self-care strategies across the Personal Health Inventory (PHI) domains. Treatment preferences and self-care strategies should be specific, promote recovery, and be strength-based.
3. Problem-solve around barriers to getting care, such as transportation and availability to attend daytime appointments.

Tailored follow-up

As part of ongoing care, it is important for clinicians and patients to:

• Monitor patient centered progress indicators.
• Adjust the treatment plan accordingly over time based on monitoring.
• Re-evaluate and renegotiate treatment focus and components.
• Provide support surrounding barriers and challenges.

Noted are a number of new directions being taken for PTSD care, including adaptation of the traditional Prolonged Exposure (noted in detailed in the “Recommended Psychotherapy” section) model for use in primary care, non–trauma-focused interventions, new medications, personalized medicine, family-based therapies, and enhanced focus on physical health (again, in support of working with PTSD comorbidities).[7,196]

A 2018 review of 1,349 studies (29 met eligibility criteria) concluded that individuals with PTSD are 5% less likely to have healthy diets, 9% less likely to be physically active, 31% more likely to be obese, and 22% more likely to smoke.[53]  Self-care strategies can complement treatments specifically aimed at PTSD symptoms.  For example the National Center for PTSD recommends that people with PTSD do the following positive coping strategies, all of which tie into various self-care circles within the Circle of Health[54]:

• Educate yourself about PTSD
• Talk to others for support, especially people who understand
• Practice relaxation methods
• Engage in positive, healthy activities that are rewarding, meaningful, or enjoyable.
• Practice good self-care by engaging in activities such as listening to music, exercising, spending time in nature or with animals, journaling or reading inspirational text.
• Stick to your routines and follow a schedule for when you sleep, eat, work and do other day-to-day activities.
• Avoid alcohol and drugs
• Limit new and social media exposure especially if it is increasing your distress.

Many of the psychotherapeutic approaches that are beneficial in treating PTSD draw in proactive strategies, such as goal setting, increasing problem-solving or coping skills, clarifying values, and broadening social support.  These tie in nicely with the Whole Health approach.

Considerations specifically related to PTSD for each of the eight components of proactive self-care are listed below.  These are framed as specific steps a care team member can follow when advising self-care practices for someone with PTSD.  Of course, which steps are taken will vary according to each individual’s needs.

Mindful Awareness

Mindfulness research continues to grow and inform practice.  Meta-analyses note that mindfulness is effective in alleviating PTSD symptoms, has low attrition rates,[46] and medium to large effect sizes, and this included one meta-analysis focused specifically on military-related PTSD symptoms.[49,197,198]  Another meta-analysis looked at Mindfulness Based Interventions (MBI) with military Veterans and found that MBI’s outperformed other therapies on general psychological symptoms, but not PTSD.[199]  Authors of a 2017 review emphasized that mindfulness approaches should not be used as first-line treatments but nevertheless do have potential benefit.[50].  Yet, another meta-analysis concluded, through a correlational study, that as mindfulness increases, PTSD symptomology decreases.[200]  Fear extinction, in particular, may be tied to the benefits of mindful awareness for PTSD.[47]  Another meta-analysis included 18 studies of mindfulness training, concluded that longer training periods had stronger effects.[48]  These effects were not affected by sex, age, or Veteran status.  One literature review of the field of Mindfulness and PTSD noted Mindfulness Based Cognitive Therapy (MBCT) and Mindfulness Based Stress Reduction (MBSR), and their variations seem to tackle different domains of the diagnosis.[201]  MBSR was associated with improvements in terms of attentional difficulties, MBCT facilitated the connection between dysfunctional cognitive concepts and avoidant behaviors that maintain the symptomatology. Nevertheless, the active components of MBCT or MBSR that have an impact on symptom reduction are undetermined as of yet.

Developed in 2014, Trauma Interventions Using Mindfulness-Based Extinction and Reconsolidation (TIMBER) is based on Mindfulness-Based Cognitive Therapy (MBCT), and it combines principles of Mindfulness-Based Exposure Therapy trauma memories work.[51]  TIMBER is an example of how various mind-body approaches are being adapted to the care of PTSD. 

To cultivate mindful awareness, there are now many ways to weave in new technology.  For example, clinicians can recommend smartphone apps that allow Veterans to self-monitor symptoms.  Some of these are listed in the “Education” section above.  Refer to the resource section at the end of this overview as well.

One review suggested that the mechanisms of action for mindfulness as it relates to PTSD might include the following[52]:

1. Mindfulness increases ability to shift attention, so that those with PTSD can reframe how they focus on trauma-related stimuli.
2. It allows one to modify maladaptive cognitive styles, allowing one to move away from worry and rumination.
3. It enables one to adopt a nonjudgmental stance, changing the way that interpretations and negative attributions are habitually done. This can help to counteract avoidance. 

Additional research is needed to confirm these theories.

Power of the Mind

Traumatic events, by definition, overwhelm our ability to cope. When the mind becomes flooded with emotion, a circuit breaker is thrown that allows us to survive the experience fairly intact, that is, without becoming psychotic or frying out one of the brain centers. The cost of this blown circuit is emotion frozen within the body. In other words, we often unconsciously stop feeling our trauma partway into it, like a movie that is still going after the sound has been turned off. We cannot heal until we move fully through that trauma, including all the feelings of the event.

―Susan Pease Banitt,
The Trauma Tool Kit: Healing PTSD from the Inside Out

A 2018 review found that, for 15 studies that met admittance criteria, meditation, mantra repetition, breathing exercises, and yoga combined with breathwork all led to “significant improvements” in symptoms of PTSD.[55]  These studies included some post-9/11 Veterans, but 85% were in other conflicts.  A 2013 systematic review of the literature found 16 of 92 articles that met review criteria.  Studies were usually small, but there was an association between an array of mind-body practices and PTSD symptoms.[56] 

When talking about Power of the Mind with Veterans, the following points are worth considering…  Explore how the mind-body relationship manifests in daily life, noting what triggers lead to increased tension and hypervigilance.[57].  PTSD is characterized by an altered parasympathetic response to stressors, whereas mind-body approaches typically enhance this response.[58]  Teach relaxation techniques to combat hypervigilance and tension.  Although evidence is still preliminary, mindfulness-based and other related approaches, such as Acceptance and  Commitment Therapy (ACT)and Dialectical Behavioral Therapy (DBT), show promise for helping patients with PTSD.[59]  Many mind-body therapies are used frequently enough in the VA that they are most appropriately considered conventional therapies.  All of these therapies and the state of the evidence regarding their use are described in the conventional therapies section below.

Meditation

A 2019 review did not find conclusive evidence that mediation was beneficial for PTSD, but concluded that “...available empirical evidence demonstrates that meditation is associated with overall reduction in PTSD symptoms, and it improves mental and somatic quality of life in PTSD patients.”[60]  A 2018 systematic review of 15 studies found benefit for seated or gentle yoga that was accompanied by breathwork and various other types of meditation.[55] One  study looked at Veterans with PTSD and the relationship of  home meditation practice of Cognitively-Based Compassion Training (CBCT) to clinical symptoms.  Home meditation practice was associated with significant improvement in depression symptoms, negative affect and positive affect.[202]

Mantram meditation, the repetitive use of a sacred word or phrase throughout the day, was found to be feasible, associated with moderate to high satisfaction, and had a promising effect size in a small cadre of 15 Veterans.[61]  A 2012 study by the same lead authors found, in a group of 146 Veterans (66 in the intervention group), that 24% of the intervention group versus 12% of controls showed improvements in PTSD symptom severity.[62,63]  The Mantram Repetition Program (MRP), which is a portable meditative practice, was utilized with Veterans with PTSD.  It was associated with significant reductions in PTSD symptom severity. Higher frequency of meditation practice during MRP was associated with greater reductions in PTSD symptoms, anger as well as improvements in well-being.[203]  This mind-body approach shows promise but further study is needed. 

Hypnotherapy

A systematic review and meta-analysis found a large effect in favor of hypnosis-based treatment suggesting hypnosis is effective in alleviating PTSD symptoms.[204]  This approach has promise for PTSD care, but more research is needed.[64,65]

Biofeedback

Overall, there is promise on the application of Neurofeedback (NFB), which uses EEG measurements, for PTSD. Several systematic reviews in 2020 showed benefit to PTSD with NFB with large effect sizes including reductions in PTSD symptoms and suicidal thoughts.[205,206]  A study of 52 people with PTSD showed significant symptom improvement with NFB, and a 2018 systematic review found it showed promise in general for a variety of outcomes measures.[66,67] There is a need for additional research with larger sample sizes, rigorous randomization and longer follow-ups, among others.[207]

Heart Rate Variability (HRV) biofeedback was the recent subject of a meta-analysis specifically examining it as a treatment for military service members with PTSD. Results indicate that HRV biofeedback may be a viable treatment approach to reduce PTSD symptomatology with low attrition rates, ease of access, and favorable participant outlook.[208]  HRV biofeedback was combined with Cognitive Behavioral Therapy (CBT) and improved symptoms for a small group of people with noncombat-related PTSD.[69]  Pre-deployment resilience training that involved HRV biofeedback resulted in lower post-deployment PTSD symptom scores in a group of 342 Army National Guard soldiers.[70].

In a 2018 study, a group of 20 Veterans were trained using fMRI to up-regulate blood oxygen supply to their amygdalae (a structure in the lower front part of the brain), which markedly improved symptoms in 80% (versus 38% of controls using sham fMRI feedback).[68]

Guided Imagery

Research at this point for Guided Imagery is limited.  Guided Imagery should be used with caution and only by an experienced professional if a person is prone to having flashbacks.  A combination intervention and randomized controlled trial included Healing Touch and guided imagery.  It was provided to returning, combat-exposed active duty military population. There was a clinically significant reduction in PTSD and related symptoms but further studies are needed.[209]

Using imagery, but differently than typical guided visualization, is Imagery Rescripting (ImRs) intervention.  ImRs was developed as a method to help activate a traumatic memory, bring corrective information into the memory, create a more favorable outcome to the memory and to support the participant to discover and express inhibited trauma-related emotional responses. Patients are instructed to first imagine the beginning of a difficult memory including sensory impressions, body sensations, thoughts and emotions; then they are guided to imagine changing how the events proceeded in such a way that would satisfy current “basic needs”.  A 2023 meta-analysis addressed the efficacy of ImRs. The results suggests that imagery rescripting does address aversive memories, is effective in treating a variety of mental health disorders and similarly effective as exposure, cognitive restructuring or EMDR.[210]

Writing Therapy

A meta-analytic review found exposure‐based writing interventions for PTSD to be more efficacious when compared with waitlist conditions, placebo writing control conditions, and evidence‐based, trauma‐focused treatments.[211]  The findings were encouraging; however, the studies included in the meta-analysis had a high degree of methodological
heterogeneity.[212]

In a 2021 study, it was found that enhanced expressive writing (i.e., writing with scheduled contacts with a therapist) was as effective as traditional psychotherapy for the treatment of traumatized patients. Expressive writing without additional talking with a therapist was found to be only slightly inferior suggesting that expressive writing could provide a useful tool to promote mental health with only minimal contact with therapist.[213]

Written Exposure Therapy (WET) is another brief treatment for PTSD that is offered at many VA’s.  This manualized treatment helps to find new ways to think about traumatic experiences and to explore their meaning through engaging in written assignments that are completed during a brief five-session therapy.  A systematic review indicates that WET is an efficacious and effective treatment for PTSD symptoms across a variety of patients.  It is important to note that dropout rates for WET were generally low and less when compared with other trauma-focused treatments.[214]  One study found WET to be a promising treatment option for Veteran patients in VA clinical care settings whether delivered in-person or via telehealth.[215] 

Other treatment protocols, such as prolonged exposure for primary care acknowledge the potential power of writing about trauma by including the use of trauma narratives.[216]

When prescribing therapeutic journaling, giving instruction on how to journal is essential in ensuring proper utility of the tool and instilling self-efficacy in the patient.[217]  Journaling may be a particularly powerful intervention when access to conventional therapeutic services is constrained such as in times of crisis and in resource-limited settings.[218]  It may be especially useful for reaching trauma survivors in need of effective mental health care who live in remote areas.  It can also be a way to reach people who are unwilling or unable to engage in psychotherapy.  Expressive writing may be contraindicated for individuals who do not typically express emotions or who have severe trauma histories or psychiatric disorders.[219-221]  Refer to “Therapeutic Journaling” for more information.

Creative Arts Therapies

A 2018 review noted that evidence for Music, Art, and Drama therapies is not conclusive of clear benefit for PTSD[72]; however, several studies on art therapy  have shown  some promise. In one visual art therapy study, participants had significantly lower scores than controls at 3 months on a measure of PTSD, as well as decreased scores on anxiety, depression and trauma.[222 ]  A systematic review on art therapy and trauma noted decreased scores on trauma assessment measures.[223]  Further research is needed.

Mind-body approaches for regulating the autonomic nervous system

In 2011, the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury published a review of 13 different mind-body techniques.[73]  These were classed into the following five categories:

• Breath
• Body-based tension modulation practices, including yoga
• Mental focused practices, such as mindfulness, meditation, Guided Imagery, and iRest® Yoga Nidra.
• Mind-body programs that offered multiple techniques in the form of taught skills courses
• Biofeedback

The report concluded that

“…integrative practices designed to regulate the autonomic nervous system and improve mood stress regulation and arousal are promising.  However, in order for these and other related practices to achieve greater recognition and be used in the mainstream military health community, there is a need to compare the relative effectiveness of techniques…to each other, as well as to other more mainstream stress and energy management practices, such as exercise, counseling, and psychopharmacology.”[73]

Psychotherapies

These are featured in the “Conventional Care” section, below.

Spirit & Soul

Spirituality may be defined, generally, as what brings meaning, purpose, and connection to a person’s life.  Each of us has a unique definition of what matters most.  Traumatic experiences affect people deeply; there is a reason people refer to them as “soul wounds.”  A soul wound or soul injury separates a person from their real self, caused by unmourned loss and hurt, unforgiven guilt and shame, and fear of helplessness or loss of control.[224]  Spirituality can mean building meaning and connection again, which are central to mental health. Having them can build optimism and resiliency, and reduce depression, anxiety, and posttraumatic stress. Spirituality can help individuals manage problems like chronic pain, heart disease, diabetes, arthritis, and stroke. For example, having a spiritual practice (like praying or working with forgiveness) can help people tolerate pain and function better. Veterans can view the Spirit & Soul Whole Health for Skill Building course for an introduction.

Spirit and soul are important to explore with people with PTSD.  A 2018 review of eight studies of spiritual and religious interventions for PTSD found that seven of them showed significant benefit.[74]  Another review noted that being religious either reduced or contributed to PTSD depending on a person’s race and the presence of anxiety or depression.[75]  A review of PTSD and spirituality for combat Veterans concluded that their results suggested that “...understanding the possible spiritual context of Veterans’ trauma-related concerns might add prognostic value and equip clinicians to alleviate PTSD symptomatology among those Veterans who possess spiritual resources or are somehow struggling in this domain.”[76] Building Spiritual Strength is an 8-session group therapy that has been led by chaplains within the VA and addresses concerns about relationship with a Higher Power as well as challenges with forgiveness.[225-227]  There is evidence that it is safe, and that it reduces both PTSD symptoms and spiritual distress. It also appears to be more effective for our African-American and Latinx Veterans who are sometimes underserved.

Of course, care team members should never impose their spiritual and religious perspectives on others; as with all aspects of self-care, Whole Health is tailored to the individual.  As you develop a PHP related to Spirit and Soul, keep the following in mind:

Consider Moral Injury

Moral injury is defined as pain and suffering that arise because individuals have been damaged at the level of their moral foundation—the level of their core values.[77]  The most common definition of Moral Injury is the definition of Litz et al. (2009).  They describe Moral Injury as the “lasting psychological, biological, spiritual, behavioral, and social impact of perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs.”[228]  A morally injurious event is one that cannot be justified based on someone’s moral or personal beliefs.[78]  People feel compelled, often by an authority figure, to do something that in other circumstances, they never would have done.  As one research study puts it, 

Moral injury is an emerging construct to more fully capture the many possible psychological, ethical, and spiritual/existential challenges among persons who served in modern wars and other trauma-exposed professional groups.[79] 

Results from the national health and resilience in veterans study found that moral injury was reported by 41.8% of Veterans.[229]  These Veterans were then categorized into three previously empirically derived dimensions of moral injury: Transgressions by Others (25.5%), Transgressions by Self (10.8%) and Transgressions by Betrayal (25.5%). t Those with a history of suicide attempt reported significantly higher Transgressions by Others and Transgressions by Self. Transgressions-Self was also associated with significantly more severe suicidal ideation during the past week.[230]

Moral injury and PTSD have been described as overlapping in terms of many of the symptoms they cause, such as anger, affective disorders, substance misuse, and insomnia.  However, they are different in some respects.[80]  Moral injury is more commonly associated with feelings of alienation, guilt, shame, and regret; PTSD, in contrast, is more likely to be linked to fear, flashbacks, and memory loss. PTSD includes additional symptoms such as hyperarousal that are not central to moral injury

Recognizing symptoms early can be crucial in the timely treatment of moral injury.  When assessing moral injury, it is important to identify exposure to a potentially morally injurious event and then assess moral injury symptoms directly linked to this specific event. The Moral Injury Outcomes Scale (MIOS) has been validated with Veterans and has a 2-factor structure capturing shame and trust.[231]  The Moral Injury and Distress Scale (MIDS) is a comprehensive measure that links a potentially morally injurious event to subjective distress and moral injury symptoms and has shown strong psychometric properties across populations at high risk for moral injury, including Veterans.[232]  The Moral Injury Symptoms Scale-Military Version Short Form (MISS-M SF) is a reliable and valid measure that screens for moral injury and monitors treatment response in Veterans and active duty military with PTSD.[233]

While research related to working with moral injury is in its early stages, it is clear that healing often relies on lessening the pain of these injuries, just as one would ease any other cause of suffering. High global meaning has been found to be protective against suicidal ideation in Veterans with moral injury.[234]  This suggests that interventions helping Veterans cultivate goals, meaning, and purpose might mitigate suicidal ideation in Veterans with moral injury.

Approaches that focus on self-forgiveness, acceptance, self-compassion, and (if possible) making amends also hold promise.[235]  There is emerging evidence for adaptive disclosure and Acceptance and Commitment Therapy treatment approaches with morally injured US military Veterans.[236]  In cases in which the effects of moral injury extend beyond psychological to spiritual harms, it is recommended to include spiritual care providers in the care team.[237]

Some studies have shown that trauma-focused PTSD treatment such as PE and CPT may be effective for Veterans with moral injury.  These treatments provide an opportunity to process trauma-related guilt and shame, to make sense of the trauma and reconnect with important values.[238,239]  One study found that trauma-related guilt was likely to endure following Prolonged Exposure and Cognitive Processing Therapy highlighting that exposure-based approaches could prove unhelpful or even harmful if inadequate attention is paid to emotional processing of feelings of shame and guilt.[236]  It can be difficult for Veterans to share morally injurious experiences because of the feelings of guilt and shame associated with them. It may be the first time they are sharing their story and could be concerned that the clinician might judge them.  It is important for clinicians to convey a non-judgmental, accepting and empathic presence and stay mindful of their own morals and values.  Assessing for Veteran’s negative beliefs associated with feelings of guilt and shame as well as addressing them can be key to creating a safe environment for Veterans to work through their own morally injurious experiences and find healing.

Work with Chaplains

Under Abraham Lincoln, the Chaplain Service was established in 1865 to work with Veterans. Chaplains are professional health care providers on the interdisciplinary teams who provide spiritual care throughout the VA health care system. Chaplains also play an important role in suicide prevention.[240]  The following is a partial list of the many roles of a chaplain: providing spiritual counseling for Veterans, their immediate family members, legal guardians, family caregivers and others who are eligible for consultation, professional counseling, marriage and family counseling and training, help with advance directives, perform religion-specific ceremonies or services, such as meditation, prayer, reading holy texts, observance of holy days, etc., assist with ethical concerns, support difficult end-of-life decisions, address moral injury, forgiveness, guilt and spiritual concerns, provide grief support.[241-244]  If a person has concerns, would like to set a goal related to Spirit and Soul, or is struggling with moral injury (described above), asking for the support of a chaplain or other experienced professional is essential.[81,82]  A 2018 article made a case for contextualizing care, noting that chaplains are especially skilled at providing “nonjudgmental, person-centered, culturally relevant care rooted in communities....”[78]  A 2019 review noted that spirituality and religion are closely linked to moral injury and that  “...help from chaplains may support healing, self-regulation, and mending of relationships, moral emotions, and social connection.”[83]  As noted under Spirit and Soul section, a chaplain-directed program, Building Spiritual Strength, addresses concerns about relationship with a Higher Power as well as challenges with forgiveness.  There is evidence that it is safe, and that it reduces both PTSD symptoms and spiritual distress.  As of July 2024, across the VA, there have been 21 adoptions of this program and 59 in progress.[245]

Chapter 11 of the Passport to Whole Health features more information about chaplains.

Explore how faith affects one’s understanding of traumatic experiences

Edward Tick, who among other things has trained over 2,000 Army Chaplains, holds that PTSD is, at its core, a “soul wound” that must be addressed as such.  Drawing in chaplains, clergy, and others who can offer spiritual support, based on a patient’s personal beliefs, is appropriate.[84]  A 2005 (nonsystematic) review of 11 studies found that typically, religion and spirituality are beneficial to people in the aftermath of trauma and that traumatic experiences often lead to a deepening of religion or spirituality.[85]  Spirituality is closely linked to posttraumatic growth, which is described in the “Personal Development” section below.

Focus on Meaning

Meaning-making is defined as “retaining, reaffirming, revising, or replacing elements of [one's] orienting system to develop more nuanced, complex and useful systems.” Making meaning of trauma, moral injury and grief can assist in navigating life post trauma.[246]  Park’s Meaning Making Model posits two important aspects of meaning: global and situational meaning.[247]  Global meaning refers to an overarching framework of beliefs, goals, and sense of purpose. Situational meaning are the meanings assigned to specific experiences, such as loss or trauma. Examples of global meaning would be God’s will or seeing loss as an aspect of war. It can also happen when individuals find meaning through considering the positive implications of the loss. This might include gaining a greater appreciation for life, or experiencing “post traumatic growth” (discussed further in Personal Development section) from the event,  or reevaluating priorities.

A 2019 evaluation of data from the National Health and Resilience in Veterans Study concluded that a higher level of “global meaning” reported by Veterans was linked to a significantly lower likelihood of suicide in Veterans who experienced morally injurious experiences related to deployment.[86]

Exploring a Veteran’s MAP is fundamental to Whole Health for PTSD. Organizations such as the Tragedy Assistance Program for Survivors (TAPS) can provide access to developing meaning both through their resources, as well as opportunities to volunteer and support others who have experienced the deaths of loved ones in combat.

Find more information in the “Spirit & Soul” overview and the MyHealtheVet information on spirituality.

Family, Friends, & Co-Workers

PTSD has a negative impact on Veterans’ relationship functioning.[87]  PTSD negatively affects familial relationships. Studies have revealed that as the severity of PTSD symptoms in veterans increases, parental functioning and marital adjustment decrease.[248]  Conversely, good peer relationships during deployment reduce risk of PTSD.[88]  Positive family interactions are linked to a lower risk of PTSD over the following 12 months.[89]  A 2019 study, asking why only 6%-10% of people with trauma end up being diagnosed with PTSD, noted that a significant proportion of the risk may be explained by differences in social cognition.[90]  People with PTSD are more likely to have deficits in understanding social cues, and particularly cues related to perceiving threats. 

Consider the following when collaborating with someone with PTSD who wants to focus on relationships:

Build Community

A sense of community and community support are extremely important to strengthening well-being and mental health in many Veterans. Many Veterans with PTSD struggle to connect with others and may avoid social events due to anxiety or fear of triggering memories of their trauma. It can be common to struggle with the transition out of the military and into civilian communities.  With the loss of a sense of community, identity and belongingness often provided by the military, the inability to find a new sense of social connectedness and support may create difficulty for veterans interacting in the civilian world. This can lead to isolation and further transition challenges.[249]  In a 14-year prospective study of 1,377 American Legionnaires whose combat exposure was in Vietnam, Veterans with PTSD who showed more community involvement were more likely to show remission of their PTSD over the course of the study. On the other hand, Veterans who reported more perceived negative community attitudes at homecoming were more likely to have a chronic course of PTSD.[250]

One of the most effective ways to help veterans who struggle with PTSD build a sense of community is to provide them with opportunities to participate in social events.  Social events can help veterans connect with other people who have shared similar experiences, build friendships, and reduce feelings of isolation and loneliness.  Research has shown that social support can improve mental health outcomes, increase overall well-being, and reduce symptoms of PTSD.[251]

Often, Veterans with PTSD have a sense that they are best understood by other Veterans.  Support groups may be helpful.  Social events can take many forms, from structured like art therapy to meet-ups to outdoor activities like hiking, sports, picnics and more.  Connecting Veterans to social events that align with their unique interests is important.  These social events can provide Veterans with a sense of meaning and purpose, help them feel like they are part of something larger than themselves and their contributions are valued.[252]  It also helps them develop coping skills and strategies to manage their PTSD symptoms and provide a safe space to express their emotions and connect with others who understand what they are going through. For more information about PTSD and community, refer to the National Center for PTSD website.

PTSD symptoms affect close relationships

PTSD is associated with a range of adverse individual outcomes including significant interpersonal problems which include difficulties in intimate and family relationships. Positive social support, such as from family, spouse or close friend, is a buffer against the development or severity of PTSD and there is some evidence that having supportive family or other close relationships can make for a more successful course of trauma treatment.[253,254]

There is some data supporting family-focused therapies,[91] and the VA is placing more emphasis on therapeutic approaches that include family members.[92] In a systematic review, it was noted that a trial of 40 couples using Cognitive Behavioral Couples Therapy (CBCT) was more effective than wait list in reducing PTSD severity, anxiety, and depression. CBCT is a 15-session intervention specifically created to treat PTSD, engage a partner in treatment and improve interpersonal functioning. Another study used Structural Approach Therapy (SAT),  which is a manualized couple therapy for PTSD which includes psychoeducation, strategies for enhancing motivation, behavioral skills to reinforce positive emotions and intimacy. In a study of 57 couples, SAT was more effective than PTSD family education intervention in reducing PTSD severity.[255]

While more studies are needed, it seems there is benefit to incorporating emotion regulation skills into couple- and family-based treatments for PTSD.[93]  Be sure to discuss the extent to which family and friends are knowledgeable of the Veteran’s diagnosis and whether or not further disclosure would be beneficial.

PTSD increases the chances of interpersonal partner violence (IPV), although most individuals with PTSD do not engage in violence. According to a 2018 study, 36% of women and 34% of men have experienced physical violence, sexual violence or stalking by an intimate partner in their lifetime. Those numbers go up for Veterans and servicemembers, with some estimates reaching as high as 58%. Active duty servicemembers are three times more likely to perpetrate IPV than civilians.[256]  Referrals to the Intimate Partner Violence Assistance Program (IPVAP) is available through the VA.

As appropriate, inform patient and family with information about resources available including the PTSD Family Coach mobile app, 1-on-1 family counseling, and pamphlets available online through the National Center for PTSD, like Understanding PTSD: A Guide for Family and Friends among others.

Animal-assisted therapies may help 

Placement of a PTSD service dog was found to improve physiological and psychosocial indicators of well-being for Veterans with PTSD (the study noted that clinical significance still needs to be explored).[94]  A study of 141 post-9/11 military members and Veterans concluded that trained service dogs “may confer clinically meaningful improvements” in PTSD symptoms.[95]  Symptoms of PTSD may be directly mitigated by tasks that the service dog is trained to perform (e.g. wake from nightmares, comfort anxiety, interrupt panic attacks).[257]  In addition to benefits from trained tasks, Veterans also describe perceptions of nonjudgmental social support, feelings of safety and the ability to be more social that emerge after meeting their service dog.[258,259]

Yet another 2018 study found that therapeutic horseback riding decreased PTSD scores on different measurement scales.[96]  A systematic review and meta-analysis found Equine Assisted Services (EAS) are beneficial for post-traumatic symptoms in the short term follow-up period. However, EAS require further research and major standardization.[260]  Other research indicate EAS have been helpful in treatment in depression and anxiety and in the [ ] enhancement of resilience, quality of life [ ] and interpersonal relationships.[261-263]

The Whispers with Horses intervention [ ] was developed at a large VA medical center.[264]  It integrates mindfulness and self-compassion training in a six-session psychotherapy incorporating horses (PIH) intervention for Veterans who have experienced trauma.  Preliminary pre to post- intervention outcomes revealed significant improvements in affect, psychological flexibility and depression.  In contrast, no improvements in PTSD were reported.

Military families also appear to benefit from animal assisted interventions (AAIs) strengthening communication, relational bonds, and psychosocial well-being.[265]  The whole family can participate together in equine-assisted services and service dogs often interact with all family members.  Although many of the benefits of service dogs are often shared, spouses and children may also experience challenges, including increased financial responsibility, burden of training and care, as well as jealousy of the dog among family members.[266-268]  Clinicians should consider how to prepare veteran spouses and families for integrating service dogs into their home.[269]

Refer to the “Animal-Assisted Therapies" clinical tool and the “Recharge” overview for more information.

Moving the Body

Take care to explore whether exercise is beneficial for a person’s PTSD symptoms and if so, how.  Enhance physical activity as appropriate; refer to the “Moving the Body” overview and Chapter 5 of the Passport to Whole Health.  Study findings specific to PTSD and the benefits of physical activity include the following:

• A 2016 review concluded that regular exercise is inversely linked to PTSD and its symptoms.[97] Hyperarousal symptoms, in particular, may improve with physical activity.[98]
• Aerobic exercise in women with PTSD reduced anxiety and fear ratings to unpredictable and predictable threats, improved mood state, and increased circulating concentrations of endocannabinoids.[270,271]
• Physical activity may offer benefit in people who are resistant to standard medical treatment.[99]
• Veterans (n=47) who participated in an Integrative Exercise program (aerobic and resistance) had greater reduction in PTSD symptom severity and greater improvement in quality of life.[272] A randomized pilot study of exercise training for older Veterans (60+) found clinically significant improvements in PTSD and related conditions following exercise.[273]
• In a small group of adults, PTSD symptoms were reduced after 12 exercise sessions of 40 minutes each. Improvements were maintained at one-month follow up.[100]    Similarly, but with adolescent females, programs of exercise sessions each week led to reduced PTSD, anxiety, and depression symptoms.[101,102]
• For Veterans seeking treatment for PTSD, physical activity moderated the relationship between PTSD and pain, such that those who were active, despite high levels of pain severity or pain interference, had fewer PTSD symptoms.[274]
• In contrast, Cochrane Review did not find any research that met admittance criteria addressing whether or not sports and games decreased PTSD symptoms.[103]
• Tai Chi and Qi Gong (TCQ): A review in 2022 noted that TCQ practices have the potential to reduce symptoms and improve functioning for individuals exposed to trauma and that TCQ is feasible, acceptable, and low risk in these populations.[275] However, there is a strong need for larger, methodologically sound clinical trials.
• Military-tailored yoga for a small group of 18 Veterans with PTSD was found potentially effective as an adjunctive or stand-alone therapy.[104] However, a 2018 meta-analysis found only “...a weak recommendation for yoga as an adjunctive intervention.”[105]  A 2017 review of seven studies found that yoga “contributed to a significant overall reduction in PTSD symptoms.”[106]  Another 2017 review concluded that yoga in combination with meditation has promise as complements to conventional PTSD treatment.[107]  A 2014 trial involving yoga for 64 women with PTSD did find marked improvement in PTSD symptoms in the yoga group.[108]  In fact, 16 of the 31 participants in the yoga group no longer met criteria for PTSD at the end of the study.

Given that exercise can have overall benefits for anxiety disorders, and given that exercise tends to offer many other health benefits as well, it is reasonable to add it as an adjunct to first-line therapies.[109]  There is a growing recognition that running or walking groups can be a helpful component to PTSD specialty clinics’ treatment programs.    

Surroundings

Some surroundings-related recommendations specific to PTSD:

• Discuss how surroundings are easing or exacerbating symptoms of avoidance, arousal, or re-experiencing trauma. Surroundings on the VA Whole Health website might be a helpful tool to use. 
• Long-term exposures to green spaces are linked to less anxiety; it is reasonable to assume more time in nature may also benefit certain Veterans with PTSD.[110]
• Participating in outdoor activities can help veterans connect with nature, which has been shown to have a positive impact on mental health.[276]

Recharge

Sleep is one of our most important ways to “recharge”.  Sleep disturbances are one of the symptoms of PTSD but even after evidence-based PTSD treatments, insomnia symptoms often remain.[277]  Insomnia is known to affect daytime functioning, decrease quality of life, increase suicidal ideation, worsen PTSD symptoms and may compromise response to PTSD treatment. The prevalence of insomnia in PTSD/Post Traumatic Stress Symptoms was 63%.[278]  And clinically significant insomnia is often reported following PTSD treatment. Given this, there are studies attempting to integrate insomnia and PTSD treatments.

A combination treatment of  CBT-I (Cognitive Behavior Therapy for Insomnia) and PET (Prolonged Exposure Therapy) showed  benefit to sleep and PTSD symptoms.[279-281]  Trauma-related nightmares are also highly prevalent among Veterans and are associated with higher-severity insomnia and posttraumatic stress disorder[111] but it has also been noted that there can be fear of sleep, decreased parasympathetic activity, abnormal rapid eye movement (REM) sleep, and other factors which complicate treatment.

CBT-I can be helpful in improving sleep symptoms in patients with PTSD [112] and can often prove more effective than medications.  A Systematic review and meta-analysis have explored the effectiveness of sleep-focused therapy and found that these treatments significantly improved sleep quality and also reduced PTSD symptoms.[282]  CBT-I, which typically occurs over 6-8 sessions, has been shown to reduce trauma-related nightmares.  Brief behavioral treatment for insomnia (BBT-I) is 4 sessions and may help reduce trauma-related nightmares.[283]  Further research is needed to better understand the potential mechanisms underlying how improved sleep may reduce trauma-related nightmares.

Explore the relationship between sleep and PTSD symptoms for each individual.  Offer suggestions for improving sleep quality, falling asleep, or enhancing sleep hygiene, as appropriate.  Additionally, innovations include a TeleSleep Enterprise-Wide Initiative to improve rural Veterans' access to sleep care; telehealth applications such as the Remote Veteran Apnea Management Platform (REVAMP), Clinical Video Telehealth, and the CBT-i Coach mobile app; increased use of home sleep apnea testing (HSAT); and programs for Veterans who experience sleep disorders associated with obesity, PTSD, TBI and other conditions.[284]

Prazosin, a drug used widely in VA to help ease nightmares from posttraumatic stress, did no better than placebo pills in a large multisite clinical trial sponsored by VA's Cooperative Studies Program (CSP). The trial involved more than 300 combat Veterans at 13 VA medical centers.[285]  Half received prazosin, and half placebo. After 26 weeks, there were slight improvements in measures of nightmares and sleep distress, as well as in other PTSD symptoms, but there was no statistical difference between the two groups.[286]  Previous meta-analysis[113] had noted better results.

Refer to the “Recharge” overview for more information on CBT-I and other psychotherapeutic approaches for improving sleep.

Food & Drink

Most of the research related to nutrition and PTSD is focused on comorbidities.  Consider the following:

• A review that included nearly 590,000 subjects concluded that the odds ratio for obesity among those with PTSD is 1.55.[114] As noted previously, metabolic syndrome is highly prevalent in people with PTSD (39%), to the point where some are questioning whether PTSD should be considered a cardiovascular disease risk factor itself.[115,116]  Abnormal eating behaviors are linked to PTSD.[117] PTSD symptoms are associated with worse diet quality and that the consumption of unhealthy food may be driven by efforts to suppress emotion.[287]  Working with healthy eating patterns is essential to reduce the elevated risk of vascular disease that plagues people with PTSD.[118]
• Address alcohol use. Excessive alcohol use often is done to try to blunt PTSD symptoms but ultimately worsens symptoms and interferes with treatment.[119]
• Explore whether dietary patterns influence symptoms. Some people are more likely to be emotionally labile if they are hungry.

Personal Development

Personal Development also has a role:

• Discuss whether any activities, hobbies, and/or creative pursuits ease PTSD symptoms and whether or not Veterans have insights about this.
• Explore posttraumatic growth, which is

…the development of positive changes and outlook following trauma, including increased personal strength, identification of new possibilities, increased appreciation of life, improved relationships with others, and positive spiritual changes.[120] 

A survey of 272 primarily “older” Veterans of Operation Enduring Freedom and Operation Iraqi Freedom found that:

• 72% endorsed a significant degree of posttraumatic growth.
• 52% reported having changed priorities about what is important in life.
• 51% reported a greater appreciation for each day.
• 49% reported being better able to handle difficulties.

Of note, those with higher PTSD scores often score higher for these measures as well; it would seem that posttraumatic stress and posttraumatic growth are not opposite ends of a spectrum, but actually can coexist.[121]  Over 50% of people report moderate-to-high posttraumatic growth after a traumatic experience.[122]  A 2018 systematic review of 21 studies confirmed that moderate posttraumatic growth, not just PTSD alone, can arise for military service personnel who have experienced trauma.[123]  Similarly, data analyzed from the 2019–2020 National Health and Resilience in Veterans Study (NHRVS), which surveyed a nationally representative sample of 3,847 trauma-exposed U.S. Veterans found that 63.2% of trauma-exposed veterans and 86.4% of veterans who screened positive for PTSD endorsed moderate-or-greater posttraumatic growth.[288]  Explore what Veterans need to foster posttraumatic growth as part of their Whole Health care. 

In terms of prevention and treatment of PTSD, it is important that evidence-based PTSD therapies be offered to all Veterans.  Most research has focused on psychotherapies and pharmaceuticals. The following highlights are based on summary recommendations from the VA/DOD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder.

Overall Recommendations

General Clinical Management: Assess the patient’s condition and collaborate with the patient, family, and caregivers to determine optimal management of patient care; emphasize the use of patient-centered care and shared decision making; minimize preventable complications and morbidity; and optimize individual health outcomes and quality of life (QoL).

Diagnosis and Assessment.  Screen periodically.  See Diagnosing PTSD section, which includes information on assessment or the VA/DOD Clinical Practice Guideline for the Management of Post Traumatic Stress Disorder.  In people with suspected PTSD, offer an appropriate diagnostic evaluation.  In people diagnosed with PTSD, use self-report measures to monitor treatment progress.

Prevention.  Evidence is limited for psychotherapy or medications in the time immediately after trauma.  If someone is diagnosed with acute stress disorder, use Trauma-Focused Psychotherapy that includes exposure and/or cognitive restructuring.  Evidence for medications is insufficient.

Treatment Priorities.

Start with individual, manualized, trauma-focused psychotherapy (preferred over drug therapy).  Drug therapy or non–trauma-focused psychotherapy can be used if trauma-focused psychotherapy is not available or not preferred by a patient.  Certain medications are preferred, and other drug classes are suggested if those are ineffective.

Acupuncture and other CIH practices are not recommended as primary treatments.

Recommended Psychotherapies

Psychotherapies, sometimes classed under “Power of the Mind” as well, are being used with increasing frequency in the VA, depending on the availability of clinicians trained to offer them.  More research comparing the different therapies to one another is continuing and is still needed.[44]

The 2023 VA/DOD Clinical Practice Guideline for the Management of PTSD most strongly recommend the following three trauma-focused therapies:

Prolonged Exposure Therapy (PET)[59] is built around the idea that repeated exposure to thoughts, situations, and feelings can reduce their power to cause a person distress.  It has four main parts, which include education, breathing retraining, practice in real-world situations, and talking through one’s trauma.[125]  A 2013 study of 1931 Veterans found that PET significantly decreased PTSD-related symptoms, as well as depression.[126]

Cognitive Processing Therapy (CPT).  The primary goal of CPT is to improve mood and behavior by making efforts to change thoughts, beliefs, and expectations that are irrational or dysfunctional.  Its four main parts include learning about symptoms, enhancing awareness about thoughts and feelings, learning skills to help challenge these thoughts and feelings, and understanding how trauma changes beliefs.  Through these steps a person is able to deal with trauma in new ways.[127]

Eye Movement Desensitization and Reprocessing (EMDR).  This involves an eight-phase approach for addressing experiences that contribute to PTSD.  After taking an elaborate history and helping patients identify a target for the therapy, clinicians have them focus on a particular image, thought or sensation while their eyes follow the clinician’s finger through a series of prescribed movements.  Other stimuli might also be used.[128]  A 2024 systematic review and meta-analysis found no difference between EMDR and other psychological therapies for PTSD.[289]  A 2018 review found trauma-focused EMDR and Cognitive-Behavioral Therapy to be equally efficacious (if not slightly better) at reducing PTSD symptoms.[129,130] A 2014 meta-analysis concluded that EMDR Therapy significantly reduces PTSD symptoms, anxiety, depression, and overall distress in people with PTSD.[131] EMDR was used successfully as an early intervention to reduce the severity of post-traumatic stress symptoms in a randomized controlled trial.[290]

Other Psychotherapy Interventions for PTSD

The 2023 Clinical Guidelines had the following recommendations about other treatments for PTSD.  They felt that the evidence was insufficient currently to recommend for or against the following psychotherapies: Accelerated Resolution Therapy; Adaptive Disclosure; Acceptance and Commitment Therapy; Brief, Eclectic Psychotherapy; Dialectical Behavior Therapy; Emotional Freedom Techniques; Impact on Killing; Interpersonal Psychotherapy; Narrative Exposure Therapy; Prolonged Exposure in Primary Care; Psychodynamic Therapy; Psychoeducation; Reconsolidation of Traumatic Memories; Seeking Safety; Stress Inoculation Training; Skills Training in Affective and Interpersonal Regulation; Skills Training in Affective and Interpersonal Regulation in Primary Care; Supportive Counseling; Thought Field Therapy; Trauma-Informed Guilt Reduction; or Trauma Management Therapy.  But availability of treatment and Veteran preferences should be taken into consideration.

For more information about each individual therapy, refer to individual PTSD 101 courses on the National Center for PTSD website. Mental health services have supported the rollout training and dissemination of evidence-based PTSD treatments to large numbers of VA clinicians.  Additional rollout trainings in the past year in cognitive-behavioral treatments for insomnia and pain, as well as problem-solving skills therapy, assist PTSD patients with recovery.  These efforts are supported by didactic lectures in both psychotherapy and pharmacotherapy of PTSD, organized by the National Center for PTSD, as well as a broad array of educational courses and materials available on its website.

Pharmacotherapies

The 2023 VA/DOD guideline suggests the following: three medications with the strongest evidence for improving clinician-rated PTSD symptoms are paroxetine, sertraline, and venlafaxine. These are the most effective medications in the type of medications classified as antidepressants. Some patients might prefer to take medication, although others might strongly oppose taking any medication for their PTSD because of side effects, stigma, or perceived lack of benefit. Benzodiazepines, short acting anti-anxiety medications, and cannabis (marijuana) are not recommended for the treatment of PTSD. While both psychotherapy and medication are beneficial treatment for PTSD, trauma-focused psychotherapies are recommended over medications for the treatment of PTSD.

Prazosin, an inexpensive alpha-1 antagonist,  which has been widely used for nightmares and noted under the Recharge section,  has had conflicting outcomes.[138].  It did no better than placebo pills in a large multisite clinical trial sponsored by VA's Cooperative Studies Program (CSP) noted earlier. Prazosin has not been associated with an improvement in overall PTSD symptoms, so the 2023 VA/DoD CPG suggests against its use for treating PTSD in general.  See the full VA/DOD Clinical Practice Guideline the Management of PTSD and Acute Stress Disorder for more specifics. 

The Clinical Practice Guideline also noted that there was insufficient evidence to recommend for or against psilocybin, ayahuasca, dimethyltryptamine, ibogaine, or lysergic acid diethylamide,  as well as methylenedioxymethamphetamine assisted psychotherapy for the treatment of PTSD. They also recommended against divalproex, guanfacine, ketamine, prazosin, risperidone, tiagabine, benzodiazepines or vortioxetine for the treatment of PTSD. Low-dose ketamine has also been used with increased frequency at a subanesthetic dose. More research is needed .

In 2010, 39% of Americans with PTSD reported using complementary approaches (then referred to as complementary and alternative medicine, or CAM) in the past year, with mind-body therapies, relaxation/meditation, exercise, herbal remedies, massage, and chiropractic listed among the most popular.[139]  A 2012 survey of 125 Veterans Hospitals revealed that 96% used at least one of a list of 32 CAM therapies in their PTSD treatment programs.[139]  The majority of systematic reviews and meta-analyses conclude that “more research is needed” regarding treating PTSD with various complementary medicine modalities.[140]  Considerable research to investigate various CIH treatments for PTSD is now underway in the VA. 

In terms of CAM approaches, the Guidelines suggest Mindfulness Based Stress Reduction for the treatment of PTSD. However, they did not find sufficient evidence to recommend for or against the following mind-body interventions for the treatment of PTSD: acupuncture, Cognitively Based Compassion Training Veteran version, creative arts therapies (e.g., music, art, dance), guided imagery, hypnosis or self-hypnosis, Loving Kindness Meditation, Mantram Repetition Program, Mindfulness-Based Cognitive Therapy, other mindfulness trainings (e.g., integrative exercise, Mindfulness-Based Exposure Therapy, brief mindfulness training), relaxation training, somatic experiencing, tai chi or qigong, Transcendental Meditation, and yoga.

For a detailed summary of CIH research in PTSD, refer to the National Center for PTSD website.  The information below summarizes many of the key research findings of this and other reviews of the literature. 

Dietary Supplements

When an individual’s body undergoes extreme stress, often their need for micronutrients increases.  Veterans experiencing PTSD may want to have blood work done to test for deficiencies to determine whether multivitamin and mineral supplements are indicated.  A study of PTSD participants found 62.7% were deficient in Vitamin D.[291]  Additionally, a preventative study in New Zealand showed that there appeared clinically significantly less psychological distress shown by survivors of the 2010 earthquake as well as the 2019 mosque shooting by survivors who supplemented their diet with multivitamins and minerals following the events.[292]

A study on the gut microbiome of US veterans suffering from high levels of PTSD concluded there were alterations in the gut microbiota.[293]  The development of cardiovascular disease among the cohort was equally heightened in those with sparser microbiota populations. The use of prebiotic or probiotic foods may be recommended. [294]  A randomized clinical trial focused on the probiotic intervention with Lactobacillus reuteri in male patients with PTSD and co-occurring mild traumatic brain injury found those who took the probiotic had a lower autonomic stress response than the placebo group.[295]

There is also interest in omega-3 supplements for PTSD.  Following the East Japan earthquake, rescue workers were involved in a random parallel group trial of fish oil.[296] Whilst there appeared little benefit for men there was much more benefit in reducing PTSD symptoms in women. 

Many who recommend supplements will try supplements similar to those used for anxiety. For more information, go to the “Anxiety” overview.

Body-Based Therapies

Limited research is available to support the use of spinal manipulative therapies for PTSD.  Previous research has shown that Veterans presenting for chiropractic care have an increased prevalence of PTSD, moderate-to-severe pain intensity and negative health behaviors (e.g., obesity, smoking and having an alcohol or substance use disorder) compared with prevalence estimates in the Veteran population as a whole.[297-299]  A small cross-sectional analysis conducted in 2009 with a group of 130 Veterans with neck or low back pain found that the 21 people with PTSD were much less likely to benefit from chiropractic than those without PTSD.[141] Few studies are available on massage and PTSD.

Energy Medicine (Biofield Therapies)

Several studies have examined the impact of Healing Touch interventions to reduce PTSD in active duty military and combat veterans with benefit to PTSD. One found that there was a significant reduction in symptom severity.[300]  Another randomized controlled trial (RCT) of Healing Touch that included 123 returning active duty military personnel found statistically significant improvements in PTSD and depression symptoms.[142] A combination intervention and randomized controlled trial included Healing Touch and guided imagery.  It was provided to returning, combat-exposed active duty military population. There was a clinically significant reduction in PTSD and related symptoms but further studies are needed. More research is needed.

Whole Systems

Acupuncture has shown increasing promise for PTSD in recent years.  A 2018 systematic review and meta-analysis of seven trials with 709 participants found evidence was low-quality evidence but suggested significant benefit.[143]  A 2012 systematic review of CIH therapies for PTSD found acupuncture superior to no treatment (being waitlisted) and comparable to group-based Cognitive-Behavioral Therapy (CBT).  In that study, which did not focus specifically on Veterans, it was the only therapy found to have a moderate effect size;[140] other approaches seemed to have less of an effect.  A frequently cited 2007 study of acupuncture for PTSD found improvement in a cohort of non-Veteran males who received a series of 24 acupuncture sessions (one hour each) over 12 weeks.[144]  A separate article on acupuncture’s mechanism of action offers detailed explanations of how acupuncture might affect PTSD at the biochemical level.[145] 

Clinical Emotional Freedom Technique (EFT) Clinical EFT is an evidence-based method that combines acupressure with elements drawn from cognitive and exposure therapies. While there are numerous variants of EFT, Clinical EFT is distinguished by having been utilized in clinical trials.[301]

In a systematic review and meta-analysis published in 2023 results demonstrated that treatment with Clinical EFT resulted in significant and large effect sizes and produced treatment results similar to other evidence-based therapies.[302] Several prior meta-analysis showed similar positive results.[146] A very small study suggested that EFT may also help prevent progression from subclinical to clinical PTSD.[148].

Other studies of PTSD and  EFT found that treatment resulted in individuals being scored significantly below the clinical cutoff for PTSD and insomnia declined from moderate to mild clinical range.  Further, outcomes note significant differences in anxiety, depression, paranoia, hostility with participants (maintaining gains at 3 and 6 months) and significant differences found for changes in 6 genes and improvements in pain.[303,304] 

The 2023 VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder does not include EFT currently as one of the 3 “gold standard” treatments for PTSD. However, there is room to use these and other approaches adjunctively.

Neuromodulatory Therapies

Neuromodulatory therapies are techniques for altering nervous system circuitry using different types of electrical modulation.  Examples include deep brain stimulation, transcranial magnetic stimulation (TMS), vagal nerve stimulation, and stellate ganglion block.  To address the frequent sleep issues that Veterans with PTSD have, non-invasive brain stimulation techniques to modulate sleep and arousal were found to be  safe and show potential but require further development to be widely applicable.  A 2019 study concluded that, overall, research is insufficient to determine efficacy for these interventions, except perhaps for some benefits seen in small studies for repetitive TMS. A systematic review on the use of neuromodulation strategies (Transcranial Magnetic Stimulation, Transcranial Direct Current Stimulation, and Deep Brain Stimulation) for PTSD pooled 13 randomized clinical trials (RCTs), 11 case series, and 6 case reports for analysis. Overall, most studies reported favorable outcomes in alleviating both PTSD and depressive symptoms. Although several RCTs described significant differences when active and sham stimulations were compared, others found marginal or nonsignificant differences between groups. Also positive were studies comparing PTSD symptoms before and after treatment. The side effect profile was found to be low, with mostly mild adverse events being reported.[305]

Each of the three patients with PTSD—Todd, Erica, and Melissa—completed a Personal Health Inventory (PHI).  In every case, their care team members were careful to assess their suicide risk as a first priority and then to assess for current life stressors.  Todd reviewed his PHI with his health psychologist, who coordinated the plan with the Patient-Aligned Care Team (PACT) that had previously been assigned to him.  Erica went over hers with her primary care practitioner, who specializes in women’s health.  An important member of her care team was a social worker who could help her with her living situation.  Melissa reviewed her PHI with a nurse practitioner she often sees, then followed up on her Personalized Health Plan (PHP) with both her psychologist and her Health and Wellness Coach.

Todd decided that his MAP, his reason for wanting his health, was so that he could go back to school to study to be a counselor because “I want to help people like me, and it will help if they have someone who really knows what all this is like.”  He also intends to get into a steady relationship.  In the meantime, he plans to train as a Peer Support Specialist at his local VA.

Todd’s health plan outlined the following priorities:

1. Continue with his medications, as per his psychiatrist.
2. Work with a mental health expert who is skilled at offering trauma-based psychotherapies, which he has not yet tried.
3. Begin an MBSR course that is offered at his local VA Hospital.
4. Try acupuncture, not only for his PTSD, but also for his chronic low back pain.
5. Ramp up his exercise to 150 minutes weekly and develop a plan to ensure it happens. Of course, the physical activity will help him in many other ways, as well. Like many people with PTSD, he is at increased cardiac risk and is working on eating healthy, too. 
6. Reduce alcohol consumption and explore other healthier ways to ease his stress levels. He was given some Veteran handouts on relaxation approaches he can try even before his MBSR class starts.

Erica received help navigating the system from a clinical social worker recommended by her primary care clinician.  Once her basic needs of safety and shelter were more reliably met, she and her health coach worked together on the following:

1. Erica was evaluated by a psychiatrist skilled in the management of PTSD (she had not been established in the health care system previously).
2. The social worker on her care team ensured she was able to get her medications, including prazosin for her nightmares.
3. She began to receive regular psychotherapy. PET was difficult for her but ultimately quite helpful.  She also received CBT-I, and her sleep gradually improved.
4. Erica found a support group for women victims of sexual trauma and cultivated a support network. She ultimately chose to attend church services with some of her new-found friends/supporters.  Spirit and Soul became a high priority for her.
5. Erica “isn’t quite ready” to focus on diet and exercise, but says her health mission is “to love my body again and really be in it.” She says she will just take it “day by day” and has plans for follow up with a Health and Wellness Coach after counseling has been ongoing for a few weeks. 

Melissa appreciated the psychotherapy she received for her PTSD, and with time, she was able to return to work.  EMDR was especially helpful to her.  One thing that completing the PHI brought to her attention was that, as someone who works in health care, she wanted to do much more as far as “practicing what I preach.”  For her health mission, she noted, “I want to enhance my ability to be a healer, understanding that it starts with me.”  
Her PHP includes several steps:

1. She will begin by cutting down to, at most, a 50-hour work week (she was working 60 hours) and go back to school to do pre-med coursework.
2. She realized that she wants to be more “reassuring and present” with the people she rides with in the back of the ambulance as an EMT. She understands that starting a mindfulness-based practice (she prefers tai chi or something that allows her to stay active while she focuses her attention) can help with this and may (though more research is needed at this point) also help some of her PTSD symptoms. 

Melissa is actively exercising and paying attention to daily calorie intake as part of her plan to model healthy living.

"Posttraumatic Stress Disorder (PTSD)” was written by J. Adam Rindfleisch, MPhil, MD and updated by Shilagh A. Mirgain, PhD and Janice Singles, PsyD (2016, updated 2024).

This Whole Health overview was made possible through a collaborative effort between the University of Wisconsin Integrative Health Program, VA Office of Patient Centered Care and Cultural Transformation, and Pacific Institute for Research and Evaluation.