Psychotherapies for adults with complex presentations of PTSD: A clinical guideline and five systematic reviews with meta-analyses

Objective: To develop a clinician-guided, research-based guideline for adult outpatient psychotherapy for complex presentations of post-traumatic stress disorder (PTSD).
Methods: We used state-of-the-art methods to develop clinical guideline recommendations and conduct systematic reviews with meta-analyses for five research questions: (Q1) When treating adults with PTSD, should trauma-focused psychotherapy include exposure? Which psychotherapies are effective for PTSD with co-occurring: (Q2) personality disorder; (Q3) depression; and (Q4) dissociative disorder? (Q5) for complex PTSD (C-PTSD)?
Results: (Q1) We found no evidence of a difference between trauma-focused psychotherapies with or without exposure on PTSD symptoms (standardised mean difference (SMD) 0.02, 95% CI -0.11 to 0.15, p=0.75, I 2 =64%). (Q2) Dialectical behaviour therapy (DBT-for-PTSD) showed beneficial effects over cognitive processing therapy (CPT) on co-occurring borderline personality disorder (BPD) symptoms (mean difference (MD) -0.58, 95% CI -0.94 to -0.22, p=0.003). (Q3) Mindfulness and body-focused psychotherapies, prolonged exposure (PE), narrative exposure therapy (NET) and CPT showed beneficial effects on symptoms of PTSD and co-occurring depression. Results for present-centred therapy (PCT) were uncertain. (Q4) No statistically significant differences were found among psychotherapies for PTSD with co-occurring dissociation. (Q5) Skills training appeared promising for C-PTSD.
Conclusion: Weak clinical recommendations were reached for trauma-focused therapies with or without exposure for PTSD; DBT-for-PTSD for PTSD with co-occurring BPD; CPT, NET, PE and Mindfulness and body-focused psychotherapies for PTSD with co-occurring depression; and Skills training for C-PTSD. A weak recommendation was reached against PCT for PTSD with co-occurring depression. It is good practice to include interventions targeting dissociation for PTSD with co-occurring dissociation. Overall, the certainty of evidence was low; high-quality trials are needed to strengthen the recommendations.