Matching treatment to patients suffering from PTSD: What we know and especially what we don’t know

In 1969, Gordon Paul asked “What treatment, by whom, is most effective for this individual, with that specific problem, under which set of circumstances, and how does it come about?” (p. 62). Although we have advanced significantly since those days, we are still far from answering this question. At first, research and practice attempted to tailor treatment to diagnostic classification. These studies reported “modest differences between treatment methods that are largely independent of other factors influencing outcome” (Shapiro and Shapiro, 1982, p. 598). We now know that comparisons between treatment approaches yield only minor differences (Cuijpers, van Straten, Andersson, and van Oppen, 2008). Tailoring treatment to diagnosis requires accuracy in our diagnostic systems. However, both major diagnostic systems (DSM and ICD) ignore etiology, intrapsychic conflicts, family and social networks, and ego strengths. This neglect may affect treatment selection. In addition, since the diagnosis is determined on the basis of the appearance of a set of symptoms from a larger possible number, the heterogeneity among patients in each diagnostic category is huge. Thus, it will not be possible to find a treatment that will be equally effective with all the various manifestations of the disorder. It is important to examine patient characteristics which are not included in the diagnosis and may also influence treatment choice. Currently, there are many techniques to treat PTSD. All seem to be equally effective. However, all these methods have large dropout rates, as well as modest success rates. Thus, the main question: Which approach to employ with the client whom we are attempting to treat, remains unanswered. I will try to sketch several deciding factors influencing choice of matching treatment to our PTSD client.