Treatment of PTSD includes both nonpharmacological and pharmacological options, with many patients likely benefiting from a combination of the two. PTSD can be a very difficult disorder to treat, and outcomes in general may not be as positive as those for other anxiety disorders or for depression, particularly with respect to pharmacological treatments. Most patients with PTSD also have at least one comorbid disorder, further complicating the clinical picture.

This chapter reviews diagnostic and treatment strategies for patients with PTSD, including consideration of comorbidities. Prior to beginning any treatment for PTSD, it is important to fully inform the patient about the disorder and its treatments, including realistic expectations of treatment outcomes.

Specific pharmacologic treatments for substance dependence/abuse that may be used as adjuncts to PTSD treatment include naltrexone and acamprosate for alcohol use, methadone and buprenorphine for opiate dependence, and bupropion, varenicline, and nicotine replacement for nicotine dependence. Non-pharmacological strategies include seeking safety therapy, motivational interviewing, and support groups.

Cognitive behavioral therapy (CBT) can also be an important part of depression treatment. Combining pharmacological and cognitive behavioral therapy may be particularly important for patients with comorbid depression and PTSD in order to reach a positive outcome.

With respect to pharmacological options, the main difference between treatment for PTSD and other anxiety disorders is that benzodiazepines have well established efficacy in generalized anxiety disorder and panic disorder, whereas there is a lack of evidence for their use in PTSD. However, they should still be used with caution in patients with PTSD and comorbid anxiety.

When selecting treatment for insomnia, it is important to determine both the underlying cause, if possible, as well as contributing factors. For example, many patients with PTSD will feel a sense of heightened danger at night; furthermore, depending on the particular trauma history, the bedroom itself may be considered a dangerous environment. These patients may therefore keep the light on or have television or music playing for comfort, all of which are contrary to good sleep hygiene. Thus, in addition to addressing fears associated with sleeping, patients should be educated on proper sleep hygiene.

If insomnia persists, medication may be necessary. There are many pharmacologic options available, including sedating antidepressants, quetiapine, and sedative hypnotics. Alpha 1 antagonists may help reduce nightmares, while alpha 2 delta ligands can improve slow-wave sleep.