Post-Traumatic Stress

Neil P Roberts et al. (2019) · European journal of psychotraumatology

This systematic review and meta-analysis explored which early psychological treatments, started within three months of a traumatic event, reduce post-traumatic stress symptoms. Post-traumatic stress disorder (PTSD) involves intrusive memories, avoidance and heightened alertness that persist after trauma, and acute stress disorder (ASD) is a similar early reaction in the first month. The authors updated an earlier 2009 review, pooled 61 randomized controlled trials, and prepared it as part of the International Society for Traumatic Stress Studies treatment guidelines. Trials were split into three groups: help offered to everyone exposed to a trauma, help for people already showing symptoms, and help for people diagnosed with ASD or PTSD. Included trials tested a wide range of approaches, including trauma-focused cognitive behavioural therapy (CBT-T, which uses written, imagined or real-life exposure to the trauma), cognitive therapy without exposure, brief EMDR (eye movement desensitization and reprocessing, a therapy in which a person recalls a trauma while following guided eye movements), cognitive processing therapy, internet-based self-help and stepped collaborative care. Most participants were adults recruited after accidents, assaults, injury or intensive care. Symptom severity was compared using standardized mean differences (SMD, where negative favors treatment), and the authors rated evidence quality with GRADE. For people not screened for symptoms, no intervention was clinically better than usual care. For people with symptoms, CBT-T outperformed waitlist (SMD -0.63) and supportive counselling (SMD -0.61) after treatment, and the gap was larger in diagnosed ASD or PTSD (SMD -0.89 and -0.75). Cognitive therapy versus waitlist reached SMD -0.68, and brief EMDR reached SMD -2.50, though that result came from four small trials with only 84 participants and very low quality evidence. CBT-T and cognitive therapy performed similarly (SMD -0.19). Benefits were less consistent at 7 to 12 months, and cognitive processing therapy showed no effect in two trials. The authors judged the CBT-T, cognitive therapy and EMDR findings clinically important, whereas significant effects for collaborative care, brief dyadic therapy and a self-guided internet program in unscreened individuals were not judged clinically important. Most ratings were low or very low quality, and few trials reported adverse events. The authors suggest that CBT-T, cognitive therapy and brief EMDR are supported for symptomatic people and that routine intervention for everyone exposed is not supported. They note limits: diverse studies, many small trials, high attrition, inconsistent follow-up and thin safety data. They also caution that the large EMDR effect rests on very few participants, that pooled estimates are uncertain because most GRADE ratings were low or very low, and that non-publication of negative results cannot be excluded.

Barbara Olasov Rothbaum et al. (2012) · Biological psychiatry

This randomized pilot study with 137 civilian trauma patients explored whether starting psychotherapy within hours of a traumatic event, before the memory of the event fully consolidates (the process by which an experience becomes a stable, long-term memory), could prevent posttraumatic stress disorder (PTSD) from developing. The intervention was a modified version of prolonged exposure (PE), a therapy that reduces conditioned fear responses by having a person repeatedly revisit a feared memory in a safe setting until the fear response diminishes, a process known as fear extinction. Because most PTSD treatments begin only after symptoms are already established, this trial tested the therapy as prevention rather than as treatment of chronic illness. Participants were adults aged 18 to 65 who arrived at a Level One trauma center emergency department within 72 hours of a qualifying trauma; 137 were randomly assigned to three one-hour sessions of modified PE, delivered one week apart and beginning in the emergency department, or to assessment only. The modified PE sessions involved guided recounting of the trauma memory, discussion of the traumatic experience, and take-home exposure exercises. Blinded evaluators measured posttraumatic stress severity with a structured clinical interview (the PSS-I) and depression with a standard self-report questionnaire (the BDI-II) at 4 and 12 weeks after enrollment. Participants who received the intervention reported significantly lower posttraumatic stress severity than the assessment-only group at 4 weeks (19.09 vs. 24.54 points, p = 0.02 for the overall treatment effect) and 12 weeks (15.47 vs. 20.33 points), representing a medium-sized benefit (Cohen's d of 0.34 to 0.38, a standard measure of effect strength where 0.2 is considered small and 0.8 is considered large). By 12 weeks, significantly more intervention participants no longer met PTSD criteria than controls (74% vs. 53%, p = 0.04). Depression scores at 4 weeks were also significantly lower in the intervention group (p < 0.01, d = 0.35). The benefit was largest among rape victims, who showed a large effect (d = 0.70) at 4 weeks, notable because sexual assault carries among the highest known risk of developing PTSD. The intervention did not significantly reduce symptoms tied to participants' earlier, unrelated traumas, suggesting its effect was specific to the event that brought them to the emergency department. The findings suggest that exposure-based psychotherapy can be safely delivered within hours of trauma, in an emergency department, before a traumatic memory becomes consolidated. The authors note important limitations: no baseline PTSD measure was collected, since assessing symptoms so soon after trauma was judged invalid, so only between-group comparisons were possible; the sample was pilot-sized and not powered for smaller effects; and roughly a quarter to a third of participants did not complete follow-up assessments. The authors describe the results as establishing feasibility and call for larger replication trials.

Veerle Oosterbaan et al. (2019) · European journal of psychotraumatology

This systematic review and meta-analysis explored whether psychological help offered within 3 months of a sexual assault can reduce or prevent posttraumatic stress disorder (PTSD), a condition in which distressing memories, avoidance and heightened alertness persist after trauma. The authors searched six databases for studies from 1980 to April 2018, and excluded psychological debriefing because earlier work found it harmful. They report that this narrow question had not been reviewed before. Seven studies with 350 participants met the criteria and tested five different early interventions, a small evidence base that the authors describe as diverse in design and timing. The included studies were mostly of women in high-income countries, with average ages of 22 to 34, recruited through hospitals, forensic examinations or counselling centres. Interventions ranged from a single 9- or 17-minute educational video to a 113-minute EMDR session (eye movement desensitization and reprocessing, in which a person recalls a trauma while following guided eye movements), a modified prolonged exposure session (structured, repeated recalling of the trauma), cognitive restructuring with relaxation, and six weeks of cognitive processing therapy. Two authors independently screened studies and rated risk of bias; four studies compared with standard care were pooled. Pooling four studies, early intervention did not clearly reduce PTSD severity at 1 to 6 weeks (g = -0.28, 95% CI -0.57 to 0.02; g is a standardized effect size, where negative favors intervention), though all four leaned that way. At 2 to 12 months, a small effect just reached significance (g = -0.23, 95% CI -0.46 to 0.00), with no measured heterogeneity. Two studies that compared PTSD diagnoses found no difference between groups. Safety data were thin: only two studies reported adverse events, and none used an active strategy to detect harm, though author contact turned up no serious events. All seven studies were judged at high risk of bias, and true randomization occurred in only two of the five studies that compared treatment groups, which the authors link to a high risk of selection bias. The authors suggest that early interventions may lead to lasting reductions in PTSD severity after sexual assault, but state that definite conclusions about safety, efficacy and PTSD prevention are impossible with so few, heterogeneous, high-risk-of-bias studies. They also note that the studies used older PTSD definitions from DSM-III-R and DSM-IV. They call for trials that actively track harm, report PTSD diagnoses as well as symptom scores, compare early with later treatment, and consider cost and access for survivors.

Milou L V Covers et al. (2021) · European journal of psychotraumatology

This randomized controlled trial with 57 recent rape victims explored whether early eye movement desensitization and reprocessing (EMDR) therapy reduces post-traumatic stress more effectively than watchful waiting, the standard wait-and-monitor approach used at Dutch sexual assault centres. EMDR is a trauma-focused psychotherapy in which a therapist guides bilateral eye movements while the person recalls a distressing memory, aiming to reduce the memory's vividness and emotional charge. Watchful waiting, by contrast, involves brief check-ins, psychoeducation, and emotional support without active trauma processing. About 40% of rape victims develop post-traumatic stress disorder (PTSD) within three months, making the timing and content of early support clinically significant. Fifty-seven participants (56 women, one man; average age about 26) were randomly assigned, between two and four weeks after a rape, to either two sessions of EMDR therapy (3.5 hours total, using a protocol adapted for very recent trauma) or two brief supportive phone calls with a case manager. Symptoms were measured before treatment, right after treatment, and again at 8 and 12 weeks using clinician-rated and self-report scales covering post-traumatic stress (CAPS-5, PCL-5), anxiety and depression (HADS), dissociation (DTS), general psychological symptoms (BSI), and sexual functioning (FSFI, AOPFS). Both groups improved substantially over the 12 weeks (large effect sizes, Cohen's d around 1.5, meaning both approaches were followed by a large drop in symptoms), but EMDR was not more effective than watchful waiting for post-traumatic stress symptoms at any time point (no statistically significant difference, p > .05 throughout). EMDR did show a short-lived edge over watchful waiting on anxiety (a 2.25-point lower score on the Hospital Anxiety and Depression Scale immediately after treatment, p = .023) and on dissociative symptoms (p = .013), but both advantages faded by the 12-week follow-up. No meaningful differences emerged between the two approaches for depression, general psychological symptoms, sexual functioning, or feelings of guilt and shame. By 12 weeks, fewer EMDR participants still met PTSD diagnostic criteria than watchful-waiting participants (16% versus 35%), though this difference was not formally tested for significance. One EMDR participant left the study after an increase in suicidal thoughts and received care; the treatment was otherwise well tolerated. The authors conclude that two sessions of early EMDR conferred no lasting advantage over watchful waiting for recent rape victims and, given its lower cost, state that the findings support existing guidance favoring watchful waiting as the default early response. The comparison involved an active watchful-waiting condition rather than no treatment, so the trial cannot show whether either approach outperforms natural recovery. The sample was small, mostly female, and experienced considerable dropout (21 of 57 participants), limiting how far the results generalize to other populations. The authors call for further research into watchful waiting's own effectiveness as an early intervention.

Lei Yi et al. (2022) · Journal of translational medicine

This randomized controlled trial with 94 women explored whether a 12-week yoga program could ease symptoms of post-traumatic stress disorder (PTSD, a condition marked by intrusive memories, avoidance of reminders, and heightened arousal following a traumatic event) after a motor vehicle accident. All participants had PTSD tied specifically to a car, motorcycle, or pedestrian accident that occurred at least three months earlier. The intervention used Kripalu yoga, a style emphasizing gentle self-observation and the connection between mind and body rather than intensive physical exertion, compared against an active control condition built around social conversation and board games. Ninety-four women were randomly assigned to a yoga group (47) or control group (47); 37 and 39, respectively, completed the trial through a 3-month follow-up. The yoga group attended six 45-minute sessions across 12 weeks, practicing breath awareness, body-focused attention during postures, and tolerance of physical discomfort under a yoga instructor's guidance. The control group met on the same schedule for daily-life conversation and games. Psychological distress was measured with two self-report instruments, the Depression Anxiety Stress Scales (DASS-21) and the Impact of Event Scale-Revised (IES-R), completed at baseline, immediately after the program, and three months later. After the program, the yoga group's total IES-R score, covering intrusion, avoidance, and hyperarousal symptoms, was significantly lower than the control group's (p = 0.01, meaning the difference was unlikely due to chance), with the difference concentrated in intrusion (p = 0.002) and avoidance (p < 0.001) rather than hyperarousal, which did not differ significantly. Intrusion and avoidance remained significantly lower in the yoga group three months later (p = 0.037 and p = 0.005). On the DASS-21, total distress scores were significantly lower in the yoga group both immediately after the program (p = 0.043) and at three-month follow-up (p = 0.024), with depression (p = 0.033, then p = 0.004) and anxiety (p < 0.001, then p = 0.035) each significantly reduced compared with control. The stress subscale of the DASS-21 showed no significant difference between groups at either timepoint. Both groups improved somewhat over time, including the control group, which the authors attribute partly to the social contact built into the comparison condition. The authors describe the results as preliminary evidence that a structured yoga program reduced depression, anxiety, and the intrusion and avoidance symptoms of PTSD in women following a motor vehicle accident, while finding no measurable effect on stress or hyperarousal. The trial enrolled a relatively small, single-site sample of Chinese women, tested only one yoga style, and relied entirely on self-report questionnaires rather than clinician-rated diagnostic measures. The authors point to comparing yoga styles and isolating which specific session components drive symptom change as directions for future research.

Peter J Bayley et al. (2022) · BMJ open

This parallel-group, randomised non-inferiority trial with 85 military veterans explored whether Sudarshan Kriya Yoga (SKY) -- a structured program of breathing exercises (pranayama) and meditation -- works as well as cognitive processing therapy (CPT), a standard trauma-focused psychotherapy, for reducing post-traumatic stress disorder (PTSD) symptoms. PTSD is a condition that can develop after a traumatic event, involving re-experiencing, avoidance, and heightened arousal. A non-inferiority design tests whether a new approach is not meaningfully worse than an established one, rather than whether it is better, which is appropriate when the existing treatment is already known to be effective. Veterans (88% men, average age 57) with elevated PTSD symptom scores were randomly assigned to SKY (n=41) or CPT (n=44) at a Veterans Affairs outpatient clinic. SKY was taught in small groups over a five-day intensive workshop plus ten weekly sessions (25 hours total), combining five distinct breathing techniques with meditation. CPT consisted of twelve individual sessions over six weeks (12 hours), focused on shifting trauma-related thinking patterns. Symptom severity was measured with the PTSD Checklist-Civilian Version (PCL-C), alongside depression (Beck Depression Inventory-II) and mood (Positive and Negative Affect Schedule). Both treatments reduced PTSD symptoms by the end of six weeks (CPT: -6.8 points, effect size d=0.58; SKY: -5.6 points, d=0.41), and the small gap between them (-1.2 points, 95% CI -5.7 to 3.3) fell safely within the study's 10-point margin for calling SKY "not meaningfully worse" -- a pattern that held at 1 month and 1 year. SKY also matched CPT on depression and mood scores through the 1-month mark, though CPT pulled ahead on both by 1 year. Dropout was similar overall (SKY 27% vs CPT 34%), and among veterans who attended at least one session, fewer left SKY (9%) than CPT (29%). Two adverse events occurred in the CPT group (treatment-related distress; a hospital admission for suicidal ideation); none were reported in the SKY group. The authors describe these results as preliminary support for SKY as a non-trauma-focused option for veterans with PTSD symptoms, comparable in the short term to an established first-line therapy. They note SKY involved roughly twice the contact time of CPT, the trial ran at a single site with a moderate sample of 85 participants, and CPT's own effect size was smaller here than in some earlier veteran studies. The authors state that SKY warrants further clinical and research attention.

Nicole Redvers et al. (2020) · PloS one

This scoping review examined 249 published articles to map what is known about traditional Indigenous medicine as practiced across North America — the healing systems, ceremonies, and practitioners used by the region's approximately 7.5 million Indigenous peoples. Traditional Indigenous medicine treats a person as a whole being of body, mind, and spirit connected to family, community, and land, with healing understood as restoring "connectedness" through practices that may or may not involve a physical medicine in the Western sense. The review was built with an Indigenous Elder as co-author and content expert, deliberately using an Indigenous-led approach to synthesis rather than a purely Western critical-review method. Researchers searched six academic databases and multiple grey-literature sources from the earliest records through June 2020, screening thousands of records down to 249 included articles spanning 1888 to 2020. Ethnobotany and plant-physiology papers were excluded to keep the focus on practices and practitioners. The team sorted the literature into five themes — general traditional medicine, integration with Western medicine, ceremonial healing practices, usage patterns, and healer perspectives — without performing a formal quality assessment, a choice the authors describe as consistent with Indigenous research protocols rather than a gap. Three findings stand out. First, traditional-healer consultation rates varied widely by community, from about 17% to over 70% of people surveyed, and multiple studies found most patients never told their physician about this use. Second, within the 30 articles on ceremonial healing, a study of incarcerated adults given jail-based sweat lodge ceremonies for alcohol use disorder reported a 7% re-incarceration rate versus an estimated 30-40% for non-participants (interpret with caution: one program, not a controlled trial). Third, a 13-week "Indigenous Healing and Seeking Safety" program combining traditional and trauma-focused approaches cut trauma symptom scores by 55% (p=0.001) in a small pilot of 17 participants. The review's honest limitation is its own scope: it catalogues what has been published, it does not grade or verify the quality of any individual study, and much of the older literature was written by non-Indigenous observers whose framing the authors flag as sometimes outdated or inappropriate. For seekers and clinicians alike, the practical takeaway is that traditional Indigenous medicine is widely used, often undisclosed to conventional providers, and under-served by rigorous evaluation — a call for more research and better clinician-healer collaboration rather than a verdict on what works.