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Meta-Analysis
. 2025 Apr 15;28(1):e301158.
doi: 10.1136/bmjment-2024-301158.

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

Julie Perrine Schaug  1 , Lise Møller  2 , Nina Reinholt  3 , Dyveke Bové Illum  1 , Frida Lau Græbe  3 , Line Bang Mikkelsen  4 , Stephen Fitzgerald Austin  3   5 , Nina Nørrelykke Paulsen  6 , Adrian Maria Tremel Porsing  1 , Sophie Juul  5   7   8 , Oliver Rumle Hovmand  3   9 , Mie Sedoc Jørgensen  3 , Ida-Marie Terese Pereira Arendt  10   11   12 , Maria Quistgaard  1 , Magnus Tang Kristensen  1 , Sidsel Christine Buskbjerg Døssing  1 , Bent Rosenbaum  10 , Nicole Gremaud Rosenberg  10 , Sidse Marie Arnfred  3   13 , Ole Jakob Storebø  14   11
Affiliations
Meta-Analysis

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

Julie Perrine Schaug et al. BMJ Ment Health. .

Abstract

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, I2=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.

Prospero registration number: CRD42022376117.

Keywords: Adult psychiatry; Anxiety disorders; Depression & mood disorders; PSYCHIATRY; Personality disorders.

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Conflict of interest statement

Competing interests: No, there are no competing interests.

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