What is the recommended treatment for Post-Traumatic Stress Disorder (PTSD) according to the Canadian Network for Modern Anxiety Disorders?

Treatment of PTSD According to Canadian Network for Modern Anxiety Disorders

I cannot provide specific treatment recommendations from the Canadian Network for Modern Anxiety Disorders as this organization is not referenced in the available evidence.

However, I can provide you with the current evidence-based treatment recommendations for PTSD from major international guidelines, which represent the standard of care:

First-Line Treatment: Trauma-Focused Psychotherapy

Trauma-focused psychotherapies should be offered as the primary treatment for PTSD, with three specific modalities showing the strongest evidence: Prolonged Exposure (PE), Cognitive Processing Therapy (CPT), and Eye Movement Desensitization and Reprocessing (EMDR). 1, 2

• These therapies demonstrate that 40-87% of patients no longer meet PTSD criteria after 9-15 sessions 1, 3
• The 2023 VA/DoD Clinical Practice Guideline strongly recommends these specific manualized trauma-focused psychotherapies over pharmacotherapy as first-line treatment 1
• All three modalities show equivalent efficacy regardless of trauma type, childhood abuse history, or comorbidities 3
• Relapse rates are substantially lower after completing trauma-focused therapy compared to medication discontinuation (26-52% relapse with sertraline discontinuation versus lower rates post-CBT) 1, 3

Specific Therapy Components:

• Prolonged Exposure (PE): Includes imaginal exposure (repeated recounting of traumatic memories) and in vivo exposure (confrontation with trauma-related situations and objects) 4
• Cognitive Processing Therapy (CPT): Teaches patients to identify and challenge trauma-related irrational beliefs through evidence-based cognitive restructuring 4
• EMDR: Shows particularly strong results with standardized mean difference of -2.07 for PTSD symptom reduction 5

When to Consider Pharmacotherapy

Medication should be considered only when psychotherapy is unavailable, the patient refuses psychotherapy, or residual symptoms persist after completing psychotherapy. 3, 4

First-Line Medications:

• SSRIs are the first-line pharmacological treatment: Sertraline and paroxetine are the only FDA-approved medications for PTSD 2, 6
• Venlafaxine (SNRI) is also recommended as first-line by the 2023 VA/DoD guideline 1
• SSRIs show 53-85% of participants classified as treatment responders in controlled trials 3
• Initiate sertraline 25-50 mg daily, titrate to 200 mg/day maximum as needed 4

Medication Duration:

• Continue SSRI treatment for minimum 6-12 months after symptom remission due to high relapse rates upon discontinuation 1, 4
• Discontinuation leads to 26-52% relapse when shifted to placebo compared to only 5-16% maintained on medication 1

Critical Medications to AVOID

Benzodiazepines are absolutely contraindicated in PTSD treatment and actively worsen outcomes. 1, 3, 4

• Evidence shows 63% of patients receiving benzodiazepines developed PTSD at 6 months compared to only 23% receiving placebo 1, 3, 4
• The 2023 VA/DoD guideline strongly recommends AGAINST benzodiazepines for PTSD treatment 1
• This includes alprazolam, clonazepam, and all other benzodiazepines 1, 3

Other Interventions to Avoid:

• Psychological debriefing (single-session intervention within 24-72 hours post-trauma) should never be used - it may be harmful and worsens outcomes with 26% PTSD prevalence in debriefed patients versus 9% in controls 1, 4
• Beta-blockers have no evidence as monotherapy for established PTSD - only studied for acute prevention 1

Treatment for Specific Symptoms

PTSD-Related Nightmares and Insomnia:

• Prazosin is specifically recommended for PTSD-related nightmares (Level A evidence) 1, 4
• Dosing: Start 1 mg at bedtime, increase 1-2 mg every few days to average effective dose of 3 mg (range 1-13 mg), monitor for orthostatic hypotension 1, 4
• Never use benzodiazepines for insomnia given their documented harm in PTSD 3, 4

Complex PTSD Presentations

Do not delay trauma-focused therapy with prolonged "stabilization phases" - patients with complex presentations benefit from immediate trauma processing. 3, 4

• Trauma-focused therapies should be routinely offered to individuals with complex presentations, including those with multiple traumas, traumatic brain injuries, and past substance use disorders 1
• History of childhood sexual abuse does not negatively affect PTSD treatment response 1
• Comorbidity does not reduce the efficacy of trauma-focused treatments 1
• Emotion dysregulation and dissociative symptoms improve directly through trauma processing itself 1

Treatment Accessibility

• Video or computerized interventions produce similar effect sizes to in-person treatment and may improve access 1
• Secure video teleconferencing can effectively deliver recommended psychotherapy when in-person options are unavailable 1
• Individual trauma-focused psychotherapy has stronger evidence and is the preferred first-line approach over group therapy 1

Common Pitfalls to Avoid

• Never assume patients need prolonged stabilization before trauma processing - this delays recovery and communicates patients cannot handle their memories 4
• Assess treatment response after 8 weeks of SSRI therapy - if inadequate response with good compliance, consider switching SSRIs or augmenting with trauma-focused therapy 3
• Depression symptoms generally improve following trauma-focused psychotherapy, so treat PTSD first when depression co-occurs 1, 4
• Treatment response is unrelated to baseline depression severity 1, 4