Ways to deal with a large crowd

The panic associated with being trapped is similar to what people with PTSD feel when they are in a large crowd.

When in a large crowd, people with PTSD may feel unsafe, or as though there is no easy way to escape the situation.  In addition, people with PTSD may have concerns that they could be caught off guard at any moment. As a result, when in a large crowd, people with PTSD may feel constantly on edge, fearful, or anxious.

These negative emotions may prevent people from leaving their homes in the first place, increasing isolation and reducing quality of life.

In today’s society, crowds are difficult to avoid — especially if you live in a city, or during certain times of the year, like holidays. Large crowds may be particularly stressful if you have PTSD, as they can trigger the hyperarousal symptoms of PTSD.

Given this, it is very important to learn ways of coping with large crowds when you have PTSD. Listed below are some basic coping strategies that may help you get through a stressful situation involving a large crowd.

Practice Deep Breathing

Deep breathing is a very simple way of coping with stress and anxiety. Learning how to engage in deep breathing (also called diaphragmatic breathing) can help reduce anxious arousal and bring about relaxation. This can be a particularly useful coping strategy when you are in a situation that you can not readily get out of (such as being stuck in a large crowd).

Use Mindfulness to Cope

When in a large crowd, a person with PTSD may constantly feel as though he is in danger. These feelings may trigger unpleasant and distressing thoughts focused on all the negative things that could happen. “Buying into” these thoughts will only further increase anxiety and fear.

But learning how to take a step back from your thoughts can reduce their power to influence your emotions and behavior. Practicing mindful awareness of your thoughts is a good and simple way of distancing yourself from these distressing thoughts, allowing you to remain in touch with the present moment.

You can also use mindfulness to become more aware of your outside environment. When people are in threatening situations, their attention tends to become locked on frightening objects in their environment. Once your attention is locked on these objects, it is very difficult to disengage from them. Mindfulness of your environment can help your attention become more flexible, and as result, you may be able to more easily direct your attention to less frightening things, such as open areas, friendly faces, or comforting images.

Utilize Social Support

If you know that large crowds have the potential to cause you fear and anxiety, make sure you bring along some social support — an excellent way of coping with stress of all kinds.

Before you go out, talk with your companions about what kinds of situations have the potential to trigger your PTSD symptoms. In addition, let them know what kinds of symptoms they should look out for in you.

This way they can help you catch anxiety and fear early on, allowing them to take steps to help you cope with that anxiety and fear as soon as it arises.

Stick to a Schedule

Set a schedule for yourself. If you know you are going into a crowded place, commit to only staying in that place for a certain period of time. The longer you have to cope with stress, the harder it becomes, thus increasing the likelihood that your PTSD symptoms may be triggered.

Learn How to Cope with Triggers

It is possible that being in a large crowd may unexpectedly trigger your PTSD symptoms: not all triggers can be prevented, and the ones that tend to impact us the most are those that catch us off guard.

Therefore, it’s very important to learn how to identify and cope with triggers, such as through grounding. This way, you can be better prepared when you are unexpectedly triggered.

Breaking Down Avoidance

Dealing with large crowds is a part of life. They are unavoidable. But it’s important to make sure that fears of large crowds do not contribute to extreme avoidance behavior, such as never leaving your home. Breaking down avoidance behavior is not an easy thing to do, and in fact, it can be a very anxiety-provoking experience. But as you break down your avoidance, your anxiety will also reduce.

If you have a fear of large crowds, try out some of the coping strategies above, but start slow. Start by practicing some of the skills, such as deep breathing or mindfulness, in a place where you feel comfortable. The more practice you have in using these skills, the easier it will be to put them to use during stressful situations. You may even want to first try imagining what it would be like to be in a large crowd.

Then, slowly expose yourself to situations where there may be large crowds. As you experience success in dealing with large crowds, you’ll have more confidence in your ability to manage your fear and anxiety. There are things you can do to cope with PTSD symptoms, limiting the power they have to control your everyday life.

  • Caucasian businesswoman talking on telephone at desk


    PTSD Hassles at Work–Head ‘Em Off Using These Strategies and Tips

How a Man’s Best Friend Can Help

How a Man’s Best Friend Can Help Those Suffering From PTSD

Claire Withey
United Kingdom June 15 2017

As a Solicitor in the Military department at Bolt Burdon Kemp, I see too often our clients suffering from the crippling effects of Post Traumatic Stress Disorder (PTSD). For those who are not aware, PTSD is an anxiety disorder that may develop after an individual is exposed to one or more traumatic events. Military personnel are often posted on tour to war-stricken areas where they are involved in or witness traumatic events, the memories of which will often stay with them for the rest of their lives.

Typical symptoms of PTSD include:

  1. Re-living or re-experiencing the traumatic event. The individual often experiences nightmares, intrusive thoughts and flashbacks;
  2. An avoidance of people, places or conversations which may trigger memories of the traumatic event;
  3. Emotional numbing, to include detachment and estrangement from others, and being less interested in previously enjoyed activities;
  4. Symptoms of increased anger, irritability, poor concentration and difficulty sleeping. Individuals will become increasingly anxious and unable to deal with stressful situations as well as they used to.

For some, symptoms can take months or even years to manifest themselves. Once present, these symptoms can sadly leave individuals detached from their former lives and can lead to difficulties in social relationships as well as with occupational functioning and work. This can lead to particular problems for those making the already difficult transition from military to civilian life.

Treatment for PTSD is typically in the form of medication to alleviate the symptoms of depression and anxiety, and also trauma focused therapy either via CBT (Cognitive Behavioural Therapy) or EMDR (Eye Movement Desensitisation & Reprocessing). However, recent studies have shown that animals, in particular dogs, can have great therapeutic benefits for those suffering from PTSD.

The use of therapy animals to treat the disabled, or those who have limited or complete loss of sight or hearing is well known. They can also have great benefits for those diagnosed with autism, in particular children.

However, Animal Assisted Therapy has in more recent years been praised for its treatment of PTSD. The healing process for PTSD is often a prolonged and lonely one, but Animal Assisted Therapy can help towards making that process a little easier.

In the majority of cases, therapy involves pairing PTSD sufferers with dogs, but other animals, including horses and cats, have been shown to produce positive results. But why exactly does this special pairing help with the treatment process? This is why…..

  1. Having an animal is known to help alleviate many of the symptoms associated with PTSD, including stress and anxiety;
  2. Having a pet often helps to promote exercise, which is known to help reduce anxiety levels. It also reduces the type of environment which may lend itself to an individual developing depression, for example as a result of spending prolonged periods of time indoors;
  3. Pets demand care. They require feeding, grooming and exercise. For the traumatised soldier, this shifts the focus away from them and towards their pet and caring for their needs;
  4. Animals are accepting and non-judgmental. They do not notice a handicap or impairment;
  5. Dogs in particular can be trained to interact pro-actively with their owner when they exhibit signs of increased stress or anxiety, and help naturally reduce that feeling in their owner. It is believed to be one of the simplest remedies for an anxiety attack;
  6. They can help re-build all important confidence in their owners, and help traumatised veterans overcome the emotional numbness and withdrawal which often comes with suffering from PTSD;
  7. Teaching dogs discipline and service commands can often help improve an individual’s patience and communication skills.

The statistics support the success of this slightly non-conventional form of treatment. In one study of the benefits of using dogs as a form of therapy, psychologists noted an 82% reduction in symptoms. In some cases, they also help to reduce the individual’s reliance on medication to alleviate their symptoms.

There is also some evidence that bonding with dogs has biological effects, including elevated levels of the hormone Oxytocin. This helps improve trust, an individual’s ability to interpret facial expressions and the over-coming of paranoia, all problems which PTSD sufferers often experience.

There are a number of charities in the UK which are raising awareness and money to support therapy of this kind for PTSD sufferers, including Bravehound and Hounds for Heroes. It is hoped that now that the benefits can be clearly seen, funding in this area will increase in the future and the provision of therapy animals to those suffering from PTSD will become more of a mainstream treatment option. 

Treatment of PTSD

Today, there are good treatments available for PTSD. When you have PTSD, dealing with the past can be hard. Instead of telling others how you feel, you may keep your feelings bottled up. But talking with a therapist can help you get better.


Cognitive behavioral therapy (CBT) is one type of counseling. Research shows it is the most effective type of counseling for PTSD. The VA is providing two forms of cognitive behavioral therapy to Veterans with PTSD: Cognitive Processing Therapy (CPT) and Prolonged Exposure (PE) therapy. To learn more about these types of therapy, see our fact sheets listed on the Treatment page.

There is a similar kind of therapy called Eye Movement Desensitization and Reprocessing (EMDR) that is used for PTSD. Also, medications have been shown to be effective. A type of drug known as a selective serotonin reuptake inhibitor (SSRI), which is also used for depression, is effective for PTSD.

Types of cognitive behavioral therapy

What is cognitive therapy?

In cognitive therapy, your therapist helps you understand and change how you think about your trauma and its aftermath. Your goal is to understand how certain thoughts about your trauma cause you stress and make your symptoms worse.

You will learn to identify thoughts about the world and yourself that are making you feel afraid or upset. With the help of your therapist, you will learn to replace these thoughts with more accurate and less distressing thoughts. You will also learn ways to cope with feelings such as anger, guilt, and fear.

After a traumatic event, you might blame yourself for things you couldn’t have changed. For example, a soldier may feel guilty about decisions he or she had to make during war. Cognitive therapy, a type of CBT, helps you understand that the traumatic event you lived through was not your fault.

What is exposure therapy?

In exposure therapy your goal is to have less fear about your memories. It is based on the idea that people learn to fear thoughts, feelings, and situations that remind them of a past traumatic event.

By talking about your trauma repeatedly with a therapist, you’ll learn to get control of your thoughts and feelings about the trauma. You’ll learn that you do not have to be afraid of your memories. This may be hard at first. It might seem strange to think about stressful things on purpose. But over time, you’ll feel less overwhelmed.

With the help of your therapist, you can change how you react to the stressful memories. Talking in a place where you feel secure makes this easier.

You may focus on memories that are less upsetting before talking about worse ones. This is called “desensitization,” and it allows you to deal with bad memories a little bit at a time. Your therapist also may ask you to remember a lot of bad memories at once. This is called “flooding,” and it helps you learn not to feel overwhelmed.

You also may practice different ways to relax when you’re having a stressful memory. Breathing exercises are sometimes used for this.

What is EMDR?

Eye movement desensitization and reprocessing (EMDR) is another type of therapy for PTSD. Like other kinds of counseling, it can help change how you react to memories of your trauma.

While thinking of or talking about your memories, you’ll focus on other stimuli like eye movements, hand taps, and sounds. For example, your therapist will move his or her hand, and you’ll follow this movement with your eyes.

Experts are still learning how EMDR works, and there is disagreement about whether eye movements are a necessary part of the treatment.


Selective serotonin reuptake inhibitors (SSRIs) are a type of antidepressant medicine. These can help you feel less sad and worried. They appear to be helpful, and for some people they are very effective. SSRIs include citalopram (Celexa), fluoxetine (such as Prozac), paroxetine (Paxil), and sertraline (Zoloft).

Chemicals in your brain affect the way you feel. For example, when you have depression you may not have enough of a chemical called serotonin. SSRIs raise the level of serotonin in your brain.

There are other medications that have been used with some success. Talk to your doctor about which medications are right for you.

Other types of treatment

Some other kinds of counseling may be helpful in your recovery. However, more evidence is needed to support these types of treatment for PTSD.

Group therapy

Many people want to talk about their trauma with others who have had similar experiences.

In group therapy, you talk with a group of people who also have been through a trauma and who have PTSD. Sharing your story with others may help you feel more comfortable talking about your trauma. This can help you cope with your symptoms, memories, and other parts of your life.

Group therapy helps you build relationships with others who understand what you’ve been through. You learn to deal with emotions such as shame, guilt, anger, rage, and fear. Sharing with the group also can help you build self-confidence and trust. You’ll learn to focus on your present life, rather than feeling overwhelmed by the past.

Brief psychodynamic psychotherapy

In this type of therapy, you learn ways of dealing with emotional conflicts caused by your trauma. This therapy helps you understand how your past affects the way you feel now.

Your therapist can help you:

  • Identify what triggers your stressful memories and other symptoms
  • Find ways to cope with intense feelings about the past
  • Become more aware of your thoughts and feelings, so you can change your reactions to them
  • Raise your self-esteem

Family therapy

PTSD can affect your whole family. Your kids or your partner may not understand why you get angry sometimes, or why you’re under so much stress. They may feel scared, guilty, or even angry about your condition.

Family therapy is a type of counseling that involves your whole family. A therapist helps you and your family to communicate, maintain good relationships, and cope with tough emotions. Your family can learn more about PTSD and how it is treated.

In family therapy, each person can express his or her fears and concerns. It’s important to be honest about your feelings and to listen to others. You can talk about your PTSD symptoms and what triggers them. You also can discuss the important parts of your treatment and recovery. By doing this, your family will be better prepared to help you.

You may consider having individual therapy for your PTSD symptoms and family therapy to help you with your relationships.

How long does treatment last?

CBT treatment for PTSD often lasts for three to six months. Other types of treatment for PTSD can last longer. If you have other mental health problems as well as PTSD, treatment may last for one to two years or longer.

What if someone has PTSD and another disorder? Is the treatment different?

It is very common to have PTSD at that same time as another mental health problem. Depression, alcohol or drug abuse problems, panic disorder, and anxiety disorders often occur along with PTSD. In many cases, the PTSD treatments described above will also help with the other disorders. The best treatment results occur when both PTSD and the other problems are treated together rather than one after the other.

What will we work on in therapy?

When you begin therapy, you and your therapist should decide together what goals you hope to reach in therapy. Not every person with PTSD will have the same treatment goals. For instance, you might focus on:

  • Reducing your PTSD symptoms
  • Learning the best way to live with your symptoms
  • Learning how to cope with other problems associated with PTSD, like feeling less guilt or sadness, improving relationships at work, or communicating with friends and family

Your therapist should help you decide which of these goals seems most important to you, and he or she should discuss with you which goals might take a long time to achieve.

What can I expect from my therapist?

Your therapist should help you decide which of these goals seems most important to you, and he or she should discuss with you which goals might take a long time to achieve.

The two of you should agree at the beginning that this plan makes sense for you. You should also agree on what you will do if it does not seem to be working. If you have any questions about the treatment, your therapist should be able to answer them.

You should feel comfortable with your therapist and feel you are working as a team to tackle your problems. It can be difficult to talk about painful situations in your life, or about traumatic experiences that you’ve had. Feelings that emerge during therapy can be scary and challenging. Talking with your therapist about the process of therapy, and about your hopes and fears in regards to therapy, will help make therapy successful.

If you do not like your therapist or feel that the therapist is not helping you, it might be helpful to talk with another professional. In most cases, you should tell your therapist that you are seeking a second opinion.  

I’m Free

Facing Down PTSD, Vet is Now Soaring High

“I’m free.”

When Steven Kraus says that, you can hear it in his voice. He means it. He is free from 40 years of dealing with Posttraumatic Stress Disorder (PTSD). The 62 year old Vietnam Veteran could not even fly a year ago, the claustrophobia and panic attacks were just too much.

Today, he is taking flying lessons. He also took a commercial flight to Cincinnati in November to help his father celebrate his 89th birthday. “I couldn’t let him down. We were in Vietnam together.”

Although he had sought professional help numerous times over the past few decades, the dramatic change in Steven’s attitude and ability is due, in part, to the treatment he received through the Veterans Health Administration known as Prolonged Exposure Therapy.

Patients Learn to Tolerate Anxiety

Dr. Matthew Yoder of the Ralph H. Johnson VA Medical Center in Charleston, SC, explains the therapy which he and Steven employed to help him deal with the painful memories which caused him such stress: “Prolonged Exposure is a cutting-edge, evidence-based treatment for PTSD in which patients face their trauma-related fears. Most often, in survivors who develop PTSD, those fears are related to memories and situational triggers that remind them of the trauma.

“This treatment works with survivors who begin “approaching” and learning to tolerate, or get used to, the anxiety associated with the memories and situations, rather than avoiding them. Once a person stops avoiding their anxiety, it typically decreases significantly, often to “normal” or pre-trauma levels.

“The primary ways of exposing survivors to their trauma-related anxiety are through talking about the traumatic event, and through intentionally approaching real-life situations that are safe but continue to make them feel nervous. The more they do these things, the easier the memories and anxiety become.”

Listening to Memories Key to Treatment

After Dr. Yoder had Steven record his recollections from his tours in Vietnam, and then instructed him to listen to the tape, Steven remembers thinking, “I can’t do this.”

When the doctor insisted, Steven listened. It was not easy. Then he listened again. Better. Then, he listened again and thought, “Hey, I can handle this.” It was a lot to handle. Steven has two Purple Hearts from his duty in Vietnam. He was in combat where hundreds of soldiers were killed. The baggage he brought home from those experiences led him to alcohol, drugs, depression, anxiety attacks and “thinking I was going to spend all my life in and out of hospitals.”

Dr. Yoder explains that PTSD starts with a traumatic event in which a person feels their, or someone else’s, life is threatened, and that involves intense horror, terror or helplessness. After such events, it is normal for survivors to have intrusive thoughts about the event and to have increased nervousness about things related to the event.

According to Dr. Yoder, “For some, however, these symptoms remain for longer than one month, and the person attempts to avoid the memories and other triggers of anxiety. In these cases, the survivor develops PTSD. Attempts to avoid thinking or talking about the event, sometimes through drugs, alcohol, or over-working, keep the memory of the event from being processed and stored in the brain like other memories.

“The memory and triggers stay active, despite attempts to avoid, and the person remains anxious in ways they were not before the traumatic event happened. This anxiety is debilitating, often getting in the way of living a healthy, productive life.”

Steven’s Boss Knew He Needed Help

Steven notes that “I never heard of PTSD back then, after I left Vietnam. I just knew I had problems and I needed help.”

The boss on his construction job knew that too and told him to go the Veterans Health Administration. Several three-month stints at the Coatesville VA Medical Center in Pennsylvania, with programs focused on mental health programs, helped for a while.

Vietnam Veteran Steven Kraus flying an airplane.“It took me a little time to really get involved with their treatment. I’ve always had a problem with trust, “Steven admits.

The events of 9/11 brought a lot of things back for Steven and after he retired, his symptoms got worse.

That’s when he met Dr. Yoder, who describes his treatment of Steven: “When I met Steven, he had severe levels of PTSD symptoms. He was having weekly panic attacks, primarily while driving. Memories from Vietnam came back to him on a daily basis, causing him intense anxiety and anger. He was not sleeping well, mostly due to intense nightmares about his Vietnam experience.

“He was using alcohol heavily in an attempt to avoid his anxiety and panic attacks. Because driving was so difficult for him, he had started isolating himself from friends and family and could not be around crowds.”

Treatment Sessions via Computer Cameras

In Steven’s case, because he lives in Savannah, GA, and because there is no one trained in Prolonged Exposure Therapy at the outpatient VA clinic where he receives the majority of his health care, he was offered specialized treatment via a relatively new technology – telemedicine video therapy.

Steven, who uses social media, easily adapted to this contemporary style of treatment. He and Dr. Yoder hook up via computers and cameras and hold sessions miles apart.

“After a while, it’s just like being in the same room. I think Dr. Yoder is wonderful. I trust him,” Steven adds.

When asked how he feels about telling his story to a large audience: “It’s part of my treatment. Dealing with it. And it’s my duty to help those other Vets out there.”

What would he say to other Veterans with similar symptoms?

“You have to get past ‘why me?’ I know what they think: ‘I’m the only one with this. I can’t get help. I’m ashamed to admit it.’ Well, the VA doctors are the best in the world. There is help out there.”


VA Programs & Services

Evidence-Based Psychotherapies

Evidence-based psychotherapy is the most-highly recommended treatment for posttraumatic stress disorder (PTSD) and is one of many effective treatments for PTSD. Each VA medical center offers one or more specific evidence-based psychotherapies for PTSD. Many medical centers and clinics provide other treatments and additional psychotherapy services for posttraumatic stress (in addition to those below).

Cognitive Processing Therapy (CPT)

Cognitive Processing Therapy (CPT) is a structured, psychotherapy for the treatment of PTSD. It involves teaching individuals to identify how traumatic experiences have impacted their thinking. It also teaches individuals to evaluate and change their thoughts. CPT usually takes 12 sessions and can be delivered in individual or group format. The goal in CPT is that clients learn to have more healthy and balanced beliefs about themselves, others and the world.

I am interested in learning more about CPT

Prolonged Exposure Therapy (PE)

Prolonged Exposure (PE) Therapy is an individual treatment for PTSD and related problems. PE typically lasts for 10-15 sessions and has been shown to work for a number of individuals with varying traumas. During treatment, clients will learn about PTSD: its causes, symptoms, and the reasons you are continuing to have symptoms. In later sessions, clients start facing safe situations that they have stayed away from because they trigger memories of a trauma. These steps will begin a process of recovery and improving the quality of your life.

I am interested in learning more about PE

  • VA PTSD Program Locator: The program locator will help you find local VA PTSD programs.
  • National Center for PTSD (NCPTSD): This website contains in-depth information on PTSD and traumatic stress. You can find answers to Frequently Asked Questions about PTSD; Fact Sheets on Common Reactions; information about the Effects of Trauma on Family and Friends; and much more.

    PTSD Information

  • Prolonged Exposure Therapy and Cognitive Processing Therapy: The VA provides at least one of two evidence based treatments for PTSD at all VA Medical Centers and to its network of Community Based Outpatient Clinics via clinical video technology. These effective therapies are Prolonged Exposure Therapy and Cognitive Processing Therapy.
  • Vet Centers: Vet Centers are located in your community and stand ready to help you and your family with readjustment counseling and outreach services. Services include individual and group counseling, marital and family counseling, medical and benefits referrals, and employment counseling.
  • MyHealtheVet – PTSD: This site provides basic information on diagnosis, symptoms and treatment.
  • MakeTheConnection.net: Visit this site to view hundreds of stories from Veterans of all service eras who have overcome mental health challenges. MakeTheConnection.net is a one-stop resource where Veterans and their families and friends can privately explore information on mental health issues, hear fellow Veterans and their families share their stories of resilience, and easily find and access the support and resources they need.
    • Watch video testimonials from Veterans who have overcome PTSD, and to learn more about PTSD, its symptoms, and treatment.



Increased tolerance of negative emotions predicts Veterans’ PTSD symptom reduction

Why do patients respond in different ways to PTSD treatment? One potential explanation is their ability to accept and manage negative emotions, also called distress tolerance. A study led by National Center for PTSD investigators examined whether increases in distress tol-erance were related to Veterans’ symptom change during PTSD treatment. Two samples of Veterans in a VA residential treatment program for PTSD (n = 53) or for PTSD and comorbid substance use disorders (n = 33) participated in the study. Both programs included Cogni-tive Processing Therapy and a variety of other interventions. Veterans completed the PTSD Checklist for DSM-IV, the Distress Tolerance Scale, and the Beck Depression Inventory-II. As expected, at the beginning of treatment, more severe PTSD was associated with lower distress tolerance. On average, both samples reported increases in distress tolerance and reductions in PTSD symptoms by the end of treatment. Veterans with the greatest increases in distress tolerance had the best PTSD treatment outcomes, even when controlling for baseline PTSD and depression symptoms, perhaps because greater ability to tolerate negative emotions facilitated engagement in treatment. Future studies can examine whether increased distress tolerance actually leads to changes in PTSD symptoms (or vice-versa), and whether distress tolerance could even protect against development of PTSD.

Read the article:


Banducci, A. N., Connolly, K. M., Vujanovic, A. A., Alvarez, J., & Bonn-Miller, M. O. (2017). The impact of changes in distress tolerance on PTSD symptom severity post-treatment among veterans in residential trauma treatment. Journal of Anxiety Disorders, 47, 99-105. PILOTS ID: 46813

Randomized trials offer growing support for tech-based PTSD interventions

Web and mobile interventions are becoming increasingly available to patients with PTSD. These interventions can vary widely in the degree to which clinicians are involved in deliv-ery. Two recent trials provide support for the efficacy of very different technology-based approaches to PTSD treatment: a mobile app that involves no clinician contact and a clini-cian-led online CBT program.

Investigators from the National Center for PTSD evaluated the effectiveness of PTSD Coach, a mobile app that includes psychoeducation, assessment, and self-management tools like relaxation and grounding. The trial enrolled 120 men and women (39 years old, on average) whose total score on the PTSD Checklist was 35 or more. Participants were randomized to use PTSD Coach (n = 62) or to a waitlist (n = 68) for 3 months. Those in the PTSD Coach condi-tion were instructed to download the app and use it however they would like. On average, they reported using PTSD Coach 1-2 days a week. Compared with waitlist participants, those who used PTSD Coach showed significantly greater improvements in self-reported PTSD and depression (d’s = .41-.45) and were more likely to achieve clinically significant change in PTSD symptoms.

Read the article:

http://www.ptsd.va.gov/professional/articles/article-pdf/id47101.pdfCTU-Online Issue 11(2) April 2017 Page 2 http://www.ptsd.va.gov

In a separate trial, a team led by investigators from Freie Universität Berlin in Germany randomized older adults with full or subthreshold PTSD to a 6-week online CBT intervention called Integrative Testimonial Therapy (n = 47) or waitlist (n = 47). All participants had experienced trauma as a child or adolescent during WWII; their average age was 71 years. Those in the online CBT condition completed writing assignments on a secure web platform and received online instructions and therapeutic feedback from clinicians on each assignment. Online CBT was associated with greater improvement in PTSD symptoms than waitlist (d = .42). Gains were maintained throughout a 1-year follow up period.

Read the article:


Findings from these studies suggest that technology-based interventions—both with and without therapist facilitation—are more effective than no treatment. Notably, consistent results were found in a sample of middle-aged adults and a sample of older adults, suggesting that these treatments can benefit a range of ages. Future studies can help to determine whether there may be an optimal amount of clinician involvement for mobile and online interventions.

Knaevelsrud, C., Böttche, M., Pietrzak, R. H., Freyberger, H. J., & Kuwert, P. (2017). Efficacy and feasibility of a therapist-guided internet-based intervention for older persons with childhood traumatization: A randomized controlled trial. The American Journal of Geriatric Psychiatry. Advance online publication. PILOTS ID: 47282

Kuhn, E., Kanuri, N., Hoffman, J. E., Garvert, D. W., Ruzek, J. I., & Taylor, C. B. (2017). A randomized controlled trial of a smartphone app for posttraumatic stress disorder symptoms. Journal of Consulting and Clinical Psychology, 85, 267–273. PILOTS ID: 47101


Special issue focuses on innovative topics in PTSD

A special issue of Current Opinion in Psychology features a series of review articles that touch on some of the most important and timely issues in the field of PTSD. Topics range from recent advances in assessment, to special populations, to novel treatment delivery formats.

Read the overview:


Vujanovic, A. A., & Schnurr, P. P. (2017). Editorial overview: Advances in science and practice in traumatic stress. Current Opinion in Psychology. Advance online publication. PILOTS ID: 47358

Systematic review on PTSD dissociative subtype

A recent review by investigators at the University of Southern Denmark includes 11 studies that used either latent profile analysis or latent class analysis to investigate the dissociative subtype and identify potential risk factors.

Read the article:


Hansen, M., Ross, J., & Armour, C. (2017). Evidence of the dissociative PTSD subtype: A systematic literature review of latent class and profile analytic studies of PTSD. Journal of Affective Disorders, 213, 59–69. PILOTS ID: 47284

New adjunctive treatment addresses killing in war

Veterans who have killed in war are at risk for a number of negative mental health and functional outcomes, including PTSD. Investigators from the San Francisco VA Medical Center have developed a new treatment for individuals who report distress related to killing in war even after completing existing evidence-based treatments for PTSD. The pilot study enrolled 33 combat Veterans who had completed a trauma-focused therapy and continued to meet PTSD criteria and experience distress related to killing. Participants were randomized to the Impact of Killing (IOK) treatment or a waitlist control that allowed participants to continue treatment as usual including medication, case management, and supportive group therapy. IOK is a cognitive-behavioral intervention consisting of six to eight 60-90 minute individual sessions focused on the moral struggles of killing in war. Veterans in the IOK condition experienced improvement in self-reported PTSD and general psychiatric symptoms and greater reductions in some important maladaptive killing-related cognitions compared with the control group. These findings provide preliminary evidence that Veterans who experience distress related to killing and who do not fully respond to existing evidence-based therapies may experience additional gains by engaging in IOK. As previous research shows that patients may continue to improve by increasing the length of evidence-based treatments (see

December 2012-CTU Online), future studies comparing IOK to an extended dose of trauma-focused therapy would help to determine the importance of specifically focusing on killing.

Read the article:


Maguen, S., Burkman, K., Madden, E., Dinh, J., Bosch, J., Keyser, J., … Neylan, T. C. (2017). Impact of killing in war: A randomized controlled pilot trial. Journal of Clinical Psychology. Advance online publication. PILOTS ID: 47285

Randomized trial of CPT for acute stress disorder

Cognitive Processing Therapy is effective for people who have had chronic PTSD for years or even decades. A recent randomized trial by investigators at Flinders University in Australia suggests that CPT can also benefit patients at the opposite end of the spectrum, even before PTSD has even developed. The study included 47 women with DSM-IV acute stress disorder due to a sexual assault within the past month. Participants were randomized to a modified 6-session CPT (n = 25) or treatment as CTU-Online Issue 11(2) April 2017 Page 3 http://www.ptsd.va.gov

usual (TAU; n = 22), which included mostly non-CBT interventions such as supportive counseling or interpersonal therapy. Both groups improved after treatment, with average drops of more than 30 points on the Clinician Administered PTSD Scale. Gains were maintained over the 1-year follow up period (Cohen’s ds 0.76 to 1.45). CPT showed a slight advantage over TAU on most outcomes; at posttreatment, CPT participants were more likely to respond to treatment (>12 point reduction on the CAPS) and achieve PTSD remission (CAPS score <20). However, effect sizes were modest and differences were not statistically significant. One caveat is that not everyone with acute stress disorder goes on to develop PTSD, and some participants might have improved without intervention.

Read the article:


Nixon, R. D. V., Best, T., Wilksch, S. R., Angelakis, S., Beatty, L. J., & Weber, N. (2016). Cognitive Processing Therapy for the treatment of acute stress disorder following sexual assault: A randomised effectiveness study. Behaviour Change, 33, 232–250. PILOTS ID: 47286

Comparing refusal and dropout from pharmacotherapy vs. psychotherapy

Evidence-based treatments can only benefit those patients who are willing to engage in them. A meta-analysis led by researchers at Idaho State University investigated whether refusal and dropout differ between psychotherapy and pharmacotherapy. The meta-analysis included 186 studies, including 7 studies of PTSD, that were head-to-head comparisons of at least two of the following conditions: psychotherapy (primarily CBT), pharmacotherapy, their combination, or psychotherapy with pill placebo. On average, 8.2% of patients refused treatment and 22% of patients dropped out, with greater likelihood of refusal (OR = 1.76) and dropout (OR = 1.20) in pharmacotherapy than in psychotherapy. Patients with depression, social anxiety, panic, and anorexia/bulimia were more likely to refuse or drop out of pharmacotherapy than psychotherapy. In contrast, patients with PTSD were equally likely to refuse and drop out of pharmacotherapy as psychotherapy and their combination. PTSD patients were more likely to drop out of pharmacotherapy than psychotherapy plus placebo, although this finding was based on only one small study. Average refusal and dropout across PTSD studies were not reported, but a previous meta-analysis found that PTSD psychotherapy has low refusal (7.8%) and moderate dropout (27%) relative to other disorders (see the

October 2015 CTU-Online). Results suggest that PTSD patients may be equally likely to initially engage in and complete a full course of pharmacotherapy and psychotherapy.

Read the article:


Swift, J. K., Greenberg, R. P., Tompkins, K. A., & Parkin, S. R. (2017). Treatment refusal and premature termination in psychotherapy, pharmacotherapy, and their combination: A meta-analysis of head-to-head comparisons. Psychotherapy, 54, 47–57. PILOTS ID: 47288


Tailored help-seeking advice post-screening does not improve outcomes

The utility of screening depends on multiple factors. Although the focus is often on the quality of screening itself, what happens post-screening is important to ensure that potential cases receive needed care. A group led by investigators at King’s Centre for Military Health Research in the United Kingdom recently evalu-ated the effectiveness of tailored advice after post-deployment screening for mental disorders to facilitate the transition to care. Military personnel completed a computerized self-assessment of PTSD, depression, anxiety, and alcohol use and were then ran-domized to receive general help-seeking advice only (n = 3,840) or to screening with tailored help-seeking advice (n = 6,350) 6-12 weeks post-deployment. Follow-up assessments occurred 10-24 months later. Among participants randomized to receive tailored advice, one-third declined to view the suggestions at all; those endorsing psychiatric symptoms were more likely to view the advice than those without symptoms. Only one-third of those individuals screening positively for psychiatric symptomology sought care at follow-up. There were no differences in prevalence of disorders assessed or help-seeking behavior between groups (tailored or general advice) at follow-up. Although these findings suggest tailored advice did not result in improved outcomes or treatment engagement, mounting evidence (see the

August 2016 CTU-Online), suggests other strategies such as collaborative primary care models including screening and ready access to medical and psychiatric care may be effective.

Read the article:


Rona, R. J., Burdett, H., Khondoker, M., Chesnokov, M., Green, K., Pernet, D., … Fear, N. T. (2017). Post-deployment screening for mental disorders and tailored advice about help-seeking in the UK military: A cluster randomised controlled trial. The Lancet, 389, 1410-1423. PILOTS ID: 47287

Study shows importance of screening for TBI and PTSD after intimate partner violence

There has been significant recent attention to traumatic brain injury as a result of sports injuries and combat, but TBI also can result from interpersonal violence (IPV). A study led by research-ers from the National Center for PTSD examined the occurrence of IPV-related TBI history and its association with PTSD symptoms in a national sample of women Veterans. Of the 411 participants, 55% reported experiencing lifetime IPV. These 224 women com-pleted additional measures assessing probable IPV-related TBI history and current TBI and PTSD symptoms. Approximately 28% screened positive for IPV-related TBI history, and of those, just under half (44%) reported current TBI symptoms. Women with current TBI symptoms were nearly 6 times more likely than those with no IPV-related TBI history to have a probable PTSD diagnosis Page

(OR = 5.9). These results highlight a strong association between IPV-related TBI symptoms and PTSD among women Veterans. Clinicians should screen for both PTSD and TBI symptoms in women who report IPV in order to refer them to appropriate ser-vices. However, more work is needed to understand whether TBI resulting from IPV may differ in important ways from TBIs from other events with regard to symptom presentation or response to intervention.

Read the article:


Iverson, K. M., Dardis, C. M., & Pogoda, T. K. (2017). Traumatic brain injury and PTSD symptoms as a consequence of intimate partner violence. Comprehensive Psychiatry, 74, 80–87. PILOTS ID: 46692

A new adherence measure for an adapted CPT protocol

Evaluating adherence to manualized treatment protocols is critical for accurately interpreting outcomes in psychotherapy research. When treatments are adapted, it is important to devel-op adherence measures relevant to these adaptations. A group led by investigators at Goethe University in Germany has devel-oped the Adherence Rating Scale for CPT (ARS-CPT), designed specifically for an adapted CPT protocol addressing PTSD and borderline personality symptoms. This 10-item scale includes items from the original CPT Adherence Protocol as well as 6 items evaluating global therapeutic adherence (i.e., common factors including rapport building and time management). Validation data were collected from two independent raters who evaluated 30 randomly selected videotaped sessions of 7 therapists and 8 participants from a multicenter RCT evaluating CPT in women with co-occurring PTSD and borderline personality disorder. Interrater reliability was good to excellent across items (ICC = .70 to 1.00) with adequate internal consistency (Chronbach’s α = .56). Content validity, including relevance and appropriateness of each item, was acceptable, although less satisfactory than expected, perhaps due to the relatively small and homogeneous sample. Measures like the ARS-CPT not only help ensure treatment is pro-vided with consistency, but also can identify key components of a specific protocol, and highlight therapist training needs.


Articles authored by National Center for PTSD staff are available in full text. For other articles we


Resources for Veterans, Active-Duty Military and their Families

Any phone number that begins with 816 area code is Kansas City Mo.

Veterans of Foreign Wars (VFW) – 816-756-3390 – http://www.vfw.org

Veterans of Foreign Wars Auxiliary (VFW Auxiliary) – 816-561-8655 – http://www.vfwauxiliar.org

VFW National Home / Military & Veteran Family Helpline / 800- 313-4200 / http://www.vfwnationalhome.org

Veterans Crisis Line / 800-273-8255 / http://www.veteranscrisisline.net

Military OneSource / 800-342-6947 / http://www.militaryonesource.mil

US Department of Veterans Affairs / Benefit line: 800-827-1000 / http://www.va.gov

Military.com / http://www.military.com

Tricare / http://www.tricare.mil

Veterans Employment and training service / 800-4-USA-DOL

Assistance for Homeless Veterans / 877-4AID-VET / 877-424-3838 / http://www.va.gov/homeless

Center for Women Veterans / 855-VA-WOMEN / 855-829-6636 / http://www.va.gov/womenvet

Disabled Veterans Services, Inc. / 702-990-3893 / http://www.disabledveteransservices.org

National Military Family Association / 703-931-6632 / http://www.militaryfamily.org

National Domestic Violence Hotline / 800-799-7233 / http://www.thehotling.org

National Alliance of Families / http://www.nationalalliance.org

National Suicide Prevention Hotline / 800-273-8255 / http://www.suicidepreventionlifeline.org

Childhelp Natonal Child Abuse Hotline / 800-4-A-CHILD / 800-422-4453