Treatment of Posttraumatic Stress Disorder: A Review ARIEH Y. SHALEV, MD, OMER BONNE, MD, AND SPENCER ETH, MD This article analyzes the literature on the treatment of posttraumatic stress disorder (PTSD). It briefly exposes the theoretical basis for each treatment modality and extensively examines pharmacological, behavioral, cognitive, and psychodynamic therapies, as well as group and family therapies, hypnosis, inpatient treatment, and rehabilitation. Articles were identified by scanning Medline and PsychLit for all papers in English reporting treatment of PTSD. Anecdotal case reports were, then, excluded. Eighty one articles were identified and categorized as either biological or psychological, with the latter category further divided into behavioral, cognitive, psychodynamic, and other treatment modalities. Information regarding the type of trauma, the sample studied, the treatment method, and the results of the treatment has been extracted from each article and is presented briefly. A synthesis of findings in each area is provided. Most studies explored a single treatment modality (e.g., pharmacological, behavioral). The cumulated evidence from these studies suggests that several treatment protocols reduce PTSD symptoms and improve the patient's quality of life. The magnitude of the results, however, is often limited, and remission is rarely achieved. Given the shortcoming of unidemnsional treatment of PTSD, it is suggested that combining biological, psychological, and psycho- social treatment may yield better results. It is further argued that rehabilitative goals should replace curative techniques in those patients with chronic PTSD. A framework for identifying targets for each treatment modality is presented. Key words: biopsychosocial framework, posttraumatic stress disorder. INTRODUCTION During the past 300 years, a variety of terms have been applied to the mental sequelae of severe trauma, including: Nostalgia, Soldier's Heart, Rail- way Spine, Shell Shock, Combat Neurosis, and Com- bat Fatigue. Each of these names reflected a theoret- ical view of the cause of mental trauma (e.g., homesickness, mechanical impact, exhaustion, men- tal conflict] and its nature (neurosis, dysregulated circulation]. The current appellation, posttraumatic stress disorder (PTSD) (l), points to our current belief in stress as a cause of mental disorders. In its most recent definition (1), PTSD is a perva- sive anxiety disorder that follows exposure to stress- ful events. DSM-IV diagnostic criteria for PTSD (l) include: a) exposure or confrontation with a trau- matic event accompanied by intense fear, helpless- ness, or horror; b) persistent reexperiencing of the traumatic event, expressed by at least one of the following: recurrent and intrusive distressing recol- lections of the event, recurrent distressing dreams, From the Center for Traumatic Stress, Hadassah University Hospital, Jerusalem, Israel. Address reprint requests to: Arieh Y. Shalev, MD, Center for Traumatic Stress, Department of Psychiatry, Hadassah University Hospital, P.O. Box 12000, Jerusalem, 91120, Israel. Received for publication January 17, 1995; revision received August 10, 1995. acting or feeling as if the traumatic event were recurring, distress on exposure to cues that symbol- ize or resemble an aspect of the event, and physio- logical reactivity on exposure to cues that symbolize or resemble the trauma; c) avoidance of stimuli associated with the trauma and numbing of general responsiveness, expressed by: efforts to avoid thoughts, feelings, or conversations associated with the trauma, efforts to avoid activities, places, or people that arouse recollections of the trauma, in- ability to recall an important aspect of the trauma, markedly diminished interest in previously signifi- cant activities, feeling of detachment or estrange- ment from others, restricted range of affect, and sense of a foreshortened future (three symptoms required]; and d] persistent symptoms of increased arousal, such as difficulty falling or staying asleep, irritability or outbursts of anger, difficulty concen- trating, hypervigilance, or exaggerated startle re- sponse (two symptoms required). The duration of the disturbance must exceed 1 month, and it should be associated with significant distress or impair- ment. Several features of PTSD attest to its inherent complexity: a) Instances of recovery from PTSD regularly occur during the first year of its course (2), and 15 to 25% of the survivors of severe traumatic events may suffer from a chronic PTSD (3, 4); b) PTSD is among the few disorders for which DSM-IV specifies a cause (i.e., the traumatic event). Yet, this requirement implicitly equates common incidents, Psychosomatic Medicine 58:165-182 (1996) 165 0033-31 74/96/5802-0165S03.00/0 Copyright © 1996 by the American Psychosomatic Society