*4.2. Psychotherapy for PTSD*

Several psychotherapeutic interventions have been indicated for PTSD treatment. Some practice guidelines recommend them as first-line treatment [112,182,183]. Psychotherapeutic interventions for PTSD include both trauma-focussed ones, which are based on processing the emotional and cognitive aspects of the traumatic event, and non-trauma-focussed ones. Trauma-focussed approaches include prolonged exposure therapy (PE), cognitive processing therapy (CPT), and eye movement desensitisation and reprocessing (EMDR), which have all been considered first line psychotherapies [29,112]. On the other hand, stress inoculation training has been considered as first line non-trauma-focused psychotherapy for PTSD patients [29]. Recently, the guidelines are being increasingly questioned, as PE and CPT have high dropout rates, and only a minority of patients cease to be diagnosed with PTSD at the end of treatment [30,31]. Furthermore, recent trials have found no differences between several therapies, including the administration of sertraline hydrochloride

and non-trauma-focussed therapies which were not previously considered to constitute first line psychotherapies for PTSD patients [31]. This highlights the importance of understanding the complexity and diversity of PTSD in each patient and also the need for the clinician to be able to adapt to the patient's needs, which can change over time [30]. Interestingly, Steenkamp et al. [31] state the need for long-term personalised approaches which can rely on the building of a therapeutic relationship to achieve better outcomes. Psychodynamic psychotherapies are also useful for the treatment of PTSD [184] and quality-based reviews of randomised controlled trials have shown no significant di fference when compared with other psychotherapies, such as cognitive-behavioural therapy [185,186].

Psychotherapeutic interventions di ffer in a number of characteristics, such as the theoretical foundations, objectives, frequency of sessions, duration, required training of therapists, and the personal conditions required of potential candidates [187]. Although 30% of the results of psychotherapy are attributed to factors which are common to all of them [188], ideally we should use which ever psychotherapeutic intervention better works for each patient [189].

Daskalakis et al. [190] proposed a tree-hit model of the individual's programming sensitivity to environmental stress, depending on the timing of environmental exposure—should this have occurred during highly plastic developmental phases [191]. The genetic makeup (hit-1) interacts with early-life environmental exposure (hit-2), resulting in (endo) phenotypes (e.g., epigenetic changes and altered HPA axis function) [14] which constitute vulnerability or resilience factors, depending on the type and characteristics of later-life environmental challenges (hit-3) which confront the individual [190]. These later-life environmental challenges can also constitute the basis for psychotherapeutic repair when this three-hit model results in vulnerability and psychic su ffering.
