How would a therapist work with a patient experiencing a mild exacerbation of Post-Traumatic Stress Disorder (PTSD) who is self-reporting early warning signs of a PTSD flare?

From the Guidelines

A therapist working with a patient experiencing a mild PTSD flare with early warning signs should prioritize evidence-based, patient-centered care, focusing on manualized psychotherapies such as prolonged exposure, cognitive processing therapy, or eye movement desensitization and reprocessing psychotherapy, as recommended by the 2023 U.S. Department of Veterans Affairs and U.S. Department of Defense clinical practice guideline 1. When a patient reports early warning signs of a PTSD flare, the therapist should:

• Validate the patient's awareness and help them implement their safety plan
• Conduct a thorough assessment of current symptoms, triggers, and safety concerns, then adjust treatment accordingly
• Utilize Cognitive Behavioral Therapy (CBT) techniques, such as cognitive restructuring to address negative thought patterns and grounding exercises (5-4-3-2-1 technique using all senses), which can be immediately helpful
• Consider increasing session frequency temporarily from monthly to weekly until symptoms stabilize
• Coordinate with a psychiatrist to evaluate whether adjustments to medications like SSRIs (sertraline 50-200mg daily or paroxetine 20-60mg daily) or prazosin (1-15mg at bedtime for nightmares) are needed, as recommended by the guideline 1
• Emphasize sleep hygiene practices, including maintaining consistent sleep schedules and avoiding screens before bed
• Help the patient identify specific triggers that preceded the flare and develop targeted coping strategies This approach is supported by the guideline, which recommends the use of specific manualized psychotherapies over pharmacotherapy and emphasizes the importance of patient-centered care and shared decision making to optimize individuals' health outcomes and quality of life 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Therapist Approach to Mild PTSD Flare-Ups

When working with a patient experiencing a mild flare-up of PTSD and self-reporting early warning signs, a therapist may employ various strategies.

• The therapist may use cognitive-behavioral therapy (CBT) or eye movement desensitization and reprocessing (EMDR) techniques, as both have been shown to be effective in treating PTSD 2, 3, 4.
• EMDR may be more suitable for patients with prominent intrusion or arousal symptoms, as it has been found to be slightly superior to CBT in reducing these symptoms 2.
• The therapist may also use a combination of EMDR and CBT components, as research suggests that therapists often use a mix of techniques in practice settings 3.
• Psychoeducation about trauma may be a common element used in therapy, as it has been found to be a frequently used component by therapists 3.

Treatment Components

The therapist may assess the patient's specific needs and use various treatment components, such as:

• Core EMDR techniques, which have been found to be highly used by EMDR therapists 3.
• In vivo exposure techniques, which may be underutilized by therapists, but can be effective in reducing PTSD symptoms 3.
• Cognitive-behavioral techniques, which can help patients identify and change negative thought patterns and behaviors contributing to their PTSD symptoms.

Considerations for Therapist-Patient Collaboration

When working with a patient experiencing a mild PTSD flare-up, the therapist should:

• Collaborate with the patient to identify early warning signs and develop a plan to manage them.
• Monitor the patient's symptoms and adjust the treatment plan as needed.
• Consider the patient's individual needs and preferences when selecting treatment components.
• Be aware of their own personality factors, therapy efficacy, and anxiety, as these can influence their use of various techniques 3.