What is the treatment for recurrent flashbacks in a patient with a history of post-traumatic stress disorder (PTSD)?

From the Guidelines

If someone experiences flashbacks after years of being symptom-free, they should seek professional help from a mental health provider immediately, and treatment typically involves a combination of psychotherapy and medication, with specific manualized psychotherapies like prolonged exposure, cognitive processing therapy, or eye movement desensitization and reprocessing psychotherapy being recommended over pharmacotherapy, as stated in the 2023 U.S. Department of Veterans Affairs and U.S. Department of Defense clinical practice guideline 1. The treatment approach should prioritize the use of evidence-based therapies, and medications like paroxetine, sertraline, or venlafaxine may be considered, while benzodiazepines, cannabis, or cannabis-derived products should be avoided 1. Some key points to consider in the treatment of flashbacks include:

• The importance of seeking professional help from a mental health provider immediately
• The use of specific manualized psychotherapies like prolonged exposure, cognitive processing therapy, or eye movement desensitization and reprocessing psychotherapy
• The consideration of medications like paroxetine, sertraline, or venlafaxine
• The avoidance of benzodiazepines, cannabis, or cannabis-derived products
• The use of grounding techniques, such as the 5-4-3-2-1 method, during acute flashbacks
• The importance of regular sleep, stress management, and avoiding triggers like alcohol or drugs for prevention. It's also important to note that flashbacks can return during periods of high stress or when encountering trauma reminders, and that traumatic memories are stored differently than regular memories, making them susceptible to being triggered by environmental or emotional cues similar to the original trauma 1.

From the FDA Drug Label

PTSD, as defined by DSM-III-R/IV, requires exposure to a traumatic event that involved actual or threatened death or serious injury, or threat to the physical integrity of self or others, and a response which involves intense fear, helplessness, or horror Symptoms that occur as a result of exposure to the traumatic event include reexperiencing of the event in the form of intrusive thoughts, flashbacks or dreams, and intense psychological distress and physiological reactivity on exposure to cues to the event; The efficacy of sertraline in maintaining a response in adult patients with PTSD for up to 28 weeks following 24 weeks of open-label treatment was demonstrated in a placebo-controlled trial

The treatment for someone who has flashbacks after years of none is not directly addressed in the provided drug labels. However, sertraline is indicated for the treatment of Posttraumatic Stress Disorder (PTSD), which includes symptoms such as flashbacks.

• The dosage for PTSD is in the range of 50 to 200 mg/day.
• It is not known whether the dose of sertraline needed for maintenance treatment is identical to the dose needed to achieve an initial response.
• Patients should be periodically reassessed to determine the need for maintenance treatment 2.

From the Research

Treatment Options for Flashbacks

If someone experiences flashbacks after years of none, there are several treatment options available.

• Trauma-focused psychotherapies, such as cognitive behavioral therapy (CBT) and eye movement desensitization and reprocessing (EMDR) therapy, are effective in reducing posttraumatic stress disorder (PTSD) symptoms, including flashbacks 3, 4, 5.
• EMDR therapy is a brief, trauma-focused treatment that has been shown to be equally efficacious as CBT in reducing PTSD symptoms, including flashbacks 4, 5.
• Trauma-focused CBT and EMDR tend to be equally efficacious, with differences between the two forms of treatment probably not being of clinical significance 4.
• Medication, such as selective serotonin reuptake inhibitors (SSRIs) or serotonin/norepinephrine reuptake inhibitors (SNRIs), may also be used to treat PTSD symptoms, including flashbacks, although there is insufficient evidence to determine whether medication or trauma-focused psychotherapies are more effective 6.

Neurophysiological Basis of Treatment

Research has shown that trauma-focused therapy modalities, including EMDR and mindfulness therapy, can effectively deactivate hindbrain regions implicated in the downregulation of autonomic nervous system (ANS) hyperarousal, which can contribute to flashbacks 7.

• EMDR and trauma-focused CBT can activate the hippocampus, anterior cingulate cortex (ACC), medial prefrontal cortex (mPFC), and orbitofrontal cortex (OFC), areas that are implicated in crucial cognitive, affective, and behavioral processes that aid trauma survivors in navigating their challenges 7.

Key Considerations

When treating flashbacks, it is essential to consider the individual's specific needs and circumstances.

• A mental health professional can help determine the best course of treatment, which may involve a combination of psychotherapy and medication 3, 4, 6, 5.
• Treatment duration and frequency may vary depending on the individual's needs and the specific therapy modality used 5.