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Nov.15.2023

Posttraumatic Stress Disorder

Synopsis

Key Points

  • Risk factors for PTSD (posttraumatic stress disorder) include occupational exposure to trauma (eg, military personnel, firefighters, police officers); threatened or actual physical or sexual assault; being kidnapped or held hostage, a prisoner of war, or tortured; experiencing natural or man-made disaster, interpersonal violence, a severe motor vehicle crash, or a sudden medical catastrophic event; or witnessing a very stressful or traumatic event
  • DSM-5-TR criteria are diagnostic for PTSD r1
  • When suspected based on patient history, primary care clinicians can identify probable PTSD with a validated screening questionnaire, such as PC-PTSD-5 (Primary Care PTSD Screen for DSM-5). Ideally, diagnosis is confirmed by a trained mental health practitioner (eg, psychologist, psychiatrist, clinical social worker), often aided by a semistructured interviewing tool r2r3
  • First line treatment is trauma-focused psychotherapy and/or serotonin reuptake inhibitors (eg, paroxetine, sertraline, venlafaxine)
  • Evidence-based therapeutic modalities include prolonged exposure therapy, cognitive processing therapy, and eye movement desensitization and reprocessing r4r5
  • Comorbid conditions and PTSD complications can cause significant distress. These include substance use disorder, sleep difficulties, depression, anxiety, and social and occupational dysfunction r1
  • Prognosis varies; many patients recover within months while some have symptoms that persist for years. Relapses may occur with reminders of the traumatic event or other life stressors r1

Pitfalls

  • Patients with symptoms of PTSD may never have connected many of their symptoms to a traumatic incident, particularly if the trauma occurred many years before
  • Older adults may be reluctant to report traumatic events or admit to emotional or psychological problems

Terminology

Clinical Clarification

  • PTSD (posttraumatic stress disorder) is a psychiatric disorder associated with development of characteristic symptoms after exposure to a traumatic event that leads to significant distress or functional impairment r1
    • The following DSM-5-TR criteria are diagnostic for PTSD in children older than 6 years and adults: r1
      • Criterion A: exposure to actual or threatened death, serious injury, or sexual violence in at least 1 of the following ways:
        • Personally experiencing traumatic event(s)
        • Witnessing the event(s) in person as it occurred to others
        • Learning about the event(s) that occurred to a close friend or family member
        • Experiencing repeated or extreme exposures to aversive details of event(s)
          • Does not include exposures through electronic media, television, movies, or pictures, unless work-related
      • Criterion B: presence of at least 1 intrusion symptom associated with and occurring after the traumatic event(s)
        • Recurrent, involuntary, and intrusive distressing memories of the event(s)
          • In children older than 6 years, this may take the form of repetitive play involving themes or aspects of the event(s)
        • Recurrent distressing dreams related to the event(s)
          • In children, may take the form of frightening dreams without specific content
        • Dissociative reactions (eg, flashbacks) in which the patient feels or acts as if the event(s) were recurring
          • In children, trauma-specific reenactment may occur during play
        • Intense or prolonged psychological distress when exposed to internal or external cues related to an aspect of the event(s)
        • Marked physiologic reactions to these cues
      • Criterion C: persistent avoidance of certain stimuli associated with the event(s)
        • Efforts to avoid distressing memories, thoughts, or feelings related to the event(s)
        • Efforts to avoid external reminders of those memories, thoughts, or feelings
      • Criterion D: negative changes in cognitions and mood associated with the event(s), either starting or worsening after the event(s), as evidenced by at least 2 of the following:
        • Inability to recall key features of the traumatic event (due to dissociative amnesia; not due to head injury, alcohol, or drugs)
        • Persistent and exaggerated negative beliefs or expectations about self, others, or the world in general
        • Persistent distorted cognitions about the cause or consequence of the event(s), resulting in the patient blaming self or others
        • Persistent negative emotions (eg, fear, horror, anger, guilt, shame)
        • Markedly diminished interest or participation in significant activities
        • Feeling of detachment or estrangement from others
        • Persistent inability to experience positive emotions (eg, happiness, satisfaction, love)
      • Criterion E: changes in arousal and reactivity beginning or worsening after the event(s), as indicated by 2 or more of the following:
        • Irritable behavior and angry outbursts (with little or no provocation)
        • Reckless or self-destructive behavior
        • Hypervigilance
        • Exaggerated startle response
        • Difficulty concentrating
        • Sleep disturbance(s)
      • Criterion F: criteria B, C, D, and E must be met for more than 1 month after the traumatic event
      • Criterion G: the condition must cause clinically significant distress or impairment
      • Criterion H: condition is not attributable to substance use or any other medical condition
    • The following DSM-5-TR criteria are diagnostic for PTSD in children aged 6 years and younger: r1
      • Criterion A: exposure to actual or threatened death, serious injury, or sexual violence in at least 1 of the following ways:
        • Directly experiencing the event
        • Personally witnessing the event as it occurred to others, especially a primary caregiver
          • Does not include exposures through electronic media, television, movies, or pictures
        • Learning that the event occurred to a parent or caregiver
      • Criterion B: presence of at least 1 intrusion symptom associated with and occurring after the traumatic event(s)
        • Recurrent, involuntary, and intrusive distressing memories of the event(s)
          • Spontaneous intrusive memories may not necessarily appear to be distressing and may be expressed as play reenactment
        • Recurrent distressing dreams related to the event(s)
          • May not be obvious that the dream content is related to the traumatic event(s)
        • Dissociative reactions in which the child feels or acts as if the event(s) were recurring
          • May occur on a continuum, with child losing awareness of current surroundings in the most extreme cases
          • Trauma-specific reenactment may occur at play
        • Intense or prolonged psychological distress when exposed to internal or external cues related to an aspect of the event(s)
        • Marked psychological reactions to these cues
      • Criterion C: persistent avoidance of certain stimuli associated with the event(s) or negative alterations in cognition and mood associated with the event(s) beginning or worsening after the event(s) as evidenced by 1 or more of the following symptoms:
        • Efforts to avoid activities, places, or physical reminders that cause recollections of the traumatic event(s)
        • Efforts to avoid people, conversations, or interpersonal situations that cause memories of the traumatic event(s)
        • Substantially increased frequency of negative emotional stress (fear, guilt, sadness, shame, confusion)
        • Markedly diminished interest or participation in significant activities, including constriction of play
        • Social withdrawal
        • Persistent reduction in expression of positive emotions
      • Criterion D: changes in arousal and reactivity beginning or worsening after the event(s), as indicated by 2 or more of the following:
        • Irritable behavioral or angry outbursts with little or no provocation, expressed as verbal or physical aggression toward people or objects
        • Hypervigilance
        • Exaggerated startle response
        • Problems with concentration
        • Sleep disturbances
      • Criterion E: duration of symptoms is greater than 1 month
      • Criterion F: condition causes clinically apparent distress or interference with relationships with parents, siblings, peers, or other caregivers, or interferes with school behavior
      • Criterion G: condition is not attributable to substance use or any other medical condition

Classification

  • DSM-5-TR recognizes 2 subtypes, which may be specified for all age groups r1
    • Delayed expression
      • Defined when the full PTSD criteria are not met until 6 months after the traumatic event(s)
      • Present in about 10% of cases r6
    • Dissociative symptoms
      • Meeting the criteria for PTSD plus experiencing persistent or recurrent symptoms of depersonalization or derealization that are not attributable to substance use or another medical condition
      • Depersonalization is defined as feeling detached from one's body or mental processes as if observing them from the outside
      • Derealization is defined as feeling a sense of unreality of surroundings (eg, dreamlike, distant, distorted)
      • Present in about 14% of cases r7

Diagnosis

Clinical Presentation

History

  • The experience of trauma includes exposure to threatened death, serious bodily injury, or sexual violence; such an event is required for the diagnosis, although witnessing (rather than personally experiencing) the traumatic event may also result in PTSD (posttraumatic stress disorder) r1c1c2c3c4c5c6
    • Because patients may not associate current symptoms with a traumatic event, especially if a lot of time has passed, it is important to ask any patients who repeatedly report to primary care with unexplained physical symptoms about traumatic event(s)
    • Patients may give negative responses to all-inclusive questions (eg, "Have you ever been abused?"); specific questions (eg, "Have you ever been hit, beaten, or choked?") may be better r8
    • Males most often report combat experience, physical assault, witnessing death or assault, or being threatened with a weapon r6c7c8c9c10c11
    • Females more often report rape, sexual molestation, physical abuse, and childhood neglect r6c12c13c14c15
  • Symptoms typically begin within 3 months of the traumatic event(s) r1
    • If duration of symptoms is less than 1 month, diagnosis cannot yet be made; however, if patient otherwise appears to have symptoms of PTSD, consider diagnosis of acute stress disorder r1
    • Symptoms fall within 4 groups: intrusion, avoidance, negative changes in cognition and mood, and alterations in arousal r1
      • Intrusion symptoms
        • Recurrent, intrusive, and involuntary memories of the event(s) r1c16c17
          • Memories typically involve sensory, emotional, or physiologic components
          • Often manifests as distressing dreams that replay the event or that thematically represent the event c18
        • Reliving the experience through flashbacks that may last from seconds to hours or days r1c19
          • Flashbacks range from brief sensory intrusions to complete loss of reality and awareness of surroundings
          • Patient may act as if the event(s) were occurring at that moment
        • Intense distress or physiologic reactivity after exposure to triggering people, places, or events or physical sensations c20
      • Avoidance symptoms
        • Patient will attempt to avoid all triggers that are reminders of the event c21
        • Avoids talking about the event in detail
      • Changes in cognitions and mood c22c23
        • Emotional numbing c24
          • Loss of interest in participating in activities once enjoyed r1c25
          • A feeling of detachment from other individuals c26
          • A persistent inability to feel positive emotions r1c27
        • Persistent negative feelings c28
          • About self, including shame or guilt, which may manifest in statements such as "I am a bad person" or "My nervous system is permanently ruined"
          • About the outside world, which may manifest in statements such as "the world is a terrible and dangerous place" or "I cannot trust anyone"
        • Negative changes in cognition r1
          • Difficulty concentrating, remembering daily events, or attending to focused tasks c29c30c31
          • Loss of memory for significant parts of the event(s) c32
          • Distorted thoughts and reasoning about the cause or consequences of the event(s) r1c33
        • Difficulty regulating emotions or maintaining interpersonal relationships (particularly for those with severe, repetitive, or prolonged trauma) r1c34c35
      • Altered arousal c36
        • Heightened sensitivity to perceived threats, both those related and not related to the traumatic event(s), and increased reactivity to unexpected stimuli r1c37c38
        • Aggression with little or no provocation or a quick temper r1c39c40
        • Participation in reckless or self-destructive behavior r1c41c42
        • Difficulty falling or staying asleep or having nightmares r1c43c44
  • Symptoms manifest differently by age group
    • Children r1
      • Distressing dreams c45
        • Dream content may not be obviously related to the traumatic event(s)
      • Flashbacks can be experienced differently than in adults
        • May be manifested through play
        • Fear may not be expressed during the reexperiencing
      • Avoidance behaviors
        • In addition to avoiding people, places, and things that remind them of the trauma, school-aged children may avoid participation in new activities c46
      • Emotional and cognitive changes
        • Loss of positive expressions of emotion with increased expression of negative emotions (eg, sadness, shame, guilt) c47c48c49
        • Withdrawal from playing with friends c50
        • Developmental regression, including loss of language, may occur c51c52
      • Alterations in arousal
        • Angry outbursts or temper tantrums c53c54
    • Adolescents
      • May view themselves as cowardly c55
      • May view themselves as being changed in ways that make them undesirable to their peers c56
      • Reluctance to pursue developmental opportunities (eg, dating, driving) c57
      • May lose aspirations for the future c58
    • Older adults
      • May experience more avoidance, hyperarousal, sleep problems, and crying spells than younger people exposed to the same trauma r1c59c60c61c62
        • If PTSD begins in younger adulthood but continues into older age, symptoms of hyperarousal, avoidance, and negative cognition and moods may be reduced r1
      • Negative health perceptions are common, accompanied by increased using of primary care services c63
      • May have suicidal ideation c64
  • Patients with untreated PTSD may use primary care services frequently, with a variety of unexplained somatic concerns

Physical examination

  • Findings are typically normal unless the trauma resulted in a persistent physical injury or scarring c65
  • A mental status examination should be performed to assist with differential diagnosis r4

Causes and Risk Factors

Causes

  • Although the cause of PTSD is not fully known, it is thought to result from altered trajectory of recovery after exposure to a traumatic event r9c66
    • While many people experience a DSM-5-TR PTSD-qualifying traumatic event, most do not develop PTSD
    • A hypothesis is that altered memory mechanisms contribute to maintenances and repeated activation of traumatic memory, as opposed to processing and contextualization r10c67
    • May be associated with neurobiologic alterations in the central and autonomic nervous systems r11c68
      • Certain alterations in the brain have been associated with PTSD r11r12
        • Reduced brain volume in the hippocampus and anterior cingulate c69
        • Excessive amygdala activity c70
        • Reduced activation of the prefrontal cortex and hippocampus in response to trauma reminders

Risk factors and/or associations

Age
  • May occur at any age from the first year of life onward r1c71c72c73
    • Children and adolescents generally have been found to have a lower prevalence after exposure to trauma r1
      • This may be because data reflect previous diagnostic criteria that were not adequately developmentally informed
    • Prevalence is lower in older adults compared with the general population r1
      • However, older adults may be more susceptible to subthreshold disease
Sex
  • Females are at higher risk and tend to experience symptoms for a longer duration than males (lifetime prevalence is twice that of malesr8) r1c74c75
Ethnicity/race
  • 12-month prevalence is greater in the United States (3.5%) than in European, Asian, African, and Latin American countries (0.5%-1%) r1c76c77c78c79c80
  • In the United States specifically, higher rates have been reported for Latino people, Black people, and Native American people than for non-Latino White people, with lower rates reported in Asian American people r1c81c82c83c84c85
  • Among veterans, Black people, Hispanic people, and Native American/Alaska Native people experience a higher rate of PTSD after combat-related trauma r8c86c87c88
Other risk factors/associations
  • Exposure to stressful or traumatic events including but not limited to: r1c89
    • War (as either combatant or civilian) c90
    • Threatened or actual physical assault (eg, robbery, mugging, childhood physical abuse) c91c92
    • Threatened or actual sexual abuse (eg, forced penetration, alcohol- or drug-facilitated penetration, contact or noncontact sexual abuse, sexual trafficking) c93c94c95
      • For children, developmentally inappropriate sexual contact without physical violence or injury is considered sexual violence c96
    • Being kidnapped, held hostage, or tortured c97c98c99
    • Experiencing a terrorist attack c100
    • Being incarcerated as a prisoner of war c101
    • Experiencing a man-made or natural disaster c102c103
    • Experiencing a severe motor vehicle crash c104
    • Experiencing a traumatic medical incident
      • By DSM-5-TR criteria, not all life-threatening illnesses or medical incidents are considered traumatic events r1
      • Traumatic medical incidents are those that involve sudden catastrophic events (eg, waking during surgery, anaphylactic shock) r1c105c106
  • Witnessing stressful or traumatic events, including: r1
    • Threatened or serious injury c107
    • Unnatural death c108
    • Physical or sexual abuse c109c110
    • Domestic abuse c111
    • War c112
    • Natural or man-made disaster c113
    • Medical catastrophe in a child c114
    • Indirect exposure to violent or accidental event involving a close friend or loved one (eg, learning of an event) r1
  • The following individuals are at higher risk: r1
    • Highest risk is among survivors of rape, military combat or captivity, ethnically or politically motivated internment, or genocide (33%-50%) r1c115c116c117c118c119
    • Those with traumatic exposure on a regular basis
      • Military personnel c120
        • For military personnel, being a perpetrator of atrocities, witnessing atrocities, or killing the enemy increases risk c121c122c123
      • Police officers c124
      • Firefighters c125
      • Emergency medical personnel (eg, emergency medical technician) c126
  • Additional risk factors
    • Underlying emotional issues c127
      • Emotional problems before age 6 years r1c128
      • Previous mental disorders (eg, panic disorder, depressive disorder, obsessive-compulsive disorder, prior PTSD) r1c129c130c131c132c133
      • Personality traits such as negative affectivity r1
    • Environmental r1
      • Lower socioeconomic status c134
      • Childhood adversity c135
      • Previous exposure to trauma, particularly during childhood c136
      • Lower education or intelligence c137c138
      • Family history of psychiatric disorders c139
      • Racial or ethnic discrimination
    • Susceptibility to developing PTSD may be influenced by genetic and epigenetic factors r1
    • Posttraumatic factors
      • Inappropriate coping strategies are adopted after the trauma
      • Trauma results in personal loss or financial stress c140c141
      • Trauma results in physical disability and an inability to return to work r13c142c143
      • Adverse life events such as forced migration are experienced after the trauma c144
    • Risk is greater if:
      • Acute pain level is high after serious physical injuries r13c145
      • Trauma involves interpersonal violence c146
      • Trauma results in personal injury c147

Diagnostic Procedures

Primary diagnostic tools

  • Diagnosis is based on patient interview, which may be aided by a screening assessment tool at the initial diagnostic encounter and ideally is confirmed by a semistructured interview with a mental health professional r14r15c148c149
    • In the primary care setting, use a screening instrument to determine if patient appears likely to have PTSD
      • Brief screening questionnaire can be helpful to determine whether a person has had an event that meets DSM-5-TR criterion A, or to determine the different types of criterion A events a person has experienced
        • Brief Trauma Questionnaire r16
          • 10-item questionnaire
          • A "yes" response to any question will meet criterion A
          • Available from the US Department of Veterans Affairs r16
      • PC-PTSD-5 (Primary Care PTSD Screen for DSM-5) r14
        • 5-item screening measure
        • If this screen finds probable PTSD, consider obtaining the PTSD Checklist for DSM-5 (PCL-5) as additional provisional evidence of PTSD
        • Available from the US Department of Veterans Affairs r14
      • PCL-5 (PTSD Checklist for DSM-5) r15
        • 20-item self-report measure useful for both screening and for making a provisional diagnosis
        • Available in several versions, the PCL-5 version with criterion A is appropriate when trauma exposure has not been separately measured by some other method
        • Available from the US Department of Veterans Affairs r15
    • DSM-5 diagnostic criteria for posttraumatic stress disorder (children older than 6 years and adults).Data from American Psychiatric Association: Posttraumatic stress disorder. In: Diagnostic and Statistical Manual of Mental Disorders. 5th ed. American Psychiatric Association; 2013:271-80.
      CategoryCriteria
      Criterion A
      Exposure to actual or threatened death, serious injury, or sexual violence in at least 1 of the following ways:1. Personally experiencing traumatic event(s)
      2. Witnessing the event(s) in person as it occurred to others
      3. Learning about the event(s) that occurred to a close friend or family member
      4. Experiencing repeated or extreme exposures to details of event(s). (Does not include exposures through electronic media, television, movies, or pictures, unless work related.)
      Criterion B
      Presence of at least 1 intrusion symptom associated with and occurring after the traumatic event(s):1. Recurrent, involuntary, and intrusive distressing memories of the event(s)
      2. Recurrent distressing dreams related to the event(s)
      3. Dissociative reactions (eg, flashbacks) in which the patient feels or acts as if the event(s) were recurring
      4. Intense or prolonged psychological distress when exposed to internal or external cues related to an aspect of the event(s)
      5. Marked physiologic reactions to these cues
      Criterion C
      Persistent avoidance of certain stimuli associated with the event(s):1. Efforts to avoid distressing memories, thoughts, or feelings related to the event(s)
      2. Efforts to avoid external reminders of those memories, thoughts, or feelings
      Criterion D
      Negative changes in cognitions and mood associated with the event(s), either starting or worsening after the event(s), as evidenced by at least 2 of the following:1. Inability to recall key features of the traumatic event (due to dissociative amnesia; not due to head injury, alcohol, or drugs)
      2. Persistent and exaggerated negative beliefs or expectations about self, others, or the world in general
      3. Persistent distorted cognitions about the cause or consequence of the event(s), resulting in the patient blaming self or others
      4. Persistent negative emotions, such as fear, horror, anger, guilt, or shame
      5. Markedly diminished interest or participation in significant activities
      6. Feeling of detachment or estrangement from others
      7. Persistent inability to experience positive emotions, such as happiness, satisfaction, or love
      Criterion E
      Changes in arousal and reactivity beginning or worsening after the event(s), as indicated by 2 or more of the following:1. Irritable behavior and angry outbursts (with little or no provocation)
      2. Reckless or self-destructive behavior
      3. Hypervigilance
      4. Exaggerated startle response
      5. Difficulty concentrating
      6. Sleep disturbance(s)
      Criterion F
      Criteria B, C, D, and E must be met for more than 1 month after the traumatic event
      Criterion G
      The condition must cause clinically significant distress or impairment
      Criterion H
      The condition is not attributable to substance use or any other medical condition
  • After initial screening, if PTSD is likely, conduct an in-depth assessment to establish diagnosis; this assessment requires more time to complete and should be administered by someone knowledgeable about PTSD and trained in administering the assessment (typically a psychologist, psychiatrist, or clinical social worker) r9
    • Several semistructured interviewing tools are available to guide assessment:
      • CAPS-5 (Clinician-Administered PTSD Scale for DSM-5) r3r17
        • 30-item interview r3
        • Considered gold standard for diagnosis by the Veterans Administration; can be obtained by request from the US Department of Veterans Affairsr17
      • CAPS-CA-5 (Clinician-Administered PTSD Scale for DSM-5: Child/Adolescent Version) r17
        • For children and adolescents aged 7 years and older
        • Includes age-appropriate items and picture response options
        • Can be obtained by request from the US Department of Veterans Affairs r2
      • PSS-I-5 (PTSD Symptom Scale Interview) r3r18
        • Updated to include DSM-5 diagnostic criteria
        • Available by request from the University of Pennsylvania; details are available on the US Department of Veterans Affairs National Center for PTSD websiter18

Procedures

PC-PTSD-5 (Primary Care PTSD Screen for DSM-5) r14c150
General explanation
  • 5-item questionnaire with "yes"/"no" responses
    • Have you ever experienced an especially frightening, horrible, or traumatic event; for example, a serious accident or fire, a physical or sexual assault or abuse, an earthquake or flood, a war, seeing someone be killed or seriously injured, or having a loved one die through homicide or suicide?
      • If the patient answers "yes," move on; if the patient answers "no," the test result is negative
    • In the past month, have you:
      • 1. Had nightmares about the event(s) or thought about the event(s) when you did not want to?
      • 2. Tried hard not to think about it or went out of your way to avoid situations that reminded you of it?
      • 3. Been constantly on guard, watchful, or easily startled?
      • 4. Felt numb or detached from others, activities, or your surroundings?
      • 5. Felt guilty or unable to stop blaming yourself or others for the event(s) or any problems the event(s) may have caused?
Indication
  • Screening assessment for PTSD in a primary care setting
Interpretation of results
  • Test results are positive if the patient answers "yes" to any 3 questions r19
PCL-5 (PTSD Checklist for DSM-5) r15c151
General explanation
  • 20-item self-reported questionnaire
    • In the past month, how much were you bothered by:
      • 1. Repeated, disturbing, and unwanted memories of the stressful experience?
      • 2. Repeated, disturbing dreams of the stressful experience?
      • 3. Suddenly feeling or acting as if the stressful experience were actually happening again (as if you were actually back there reliving it)?
      • 4. Feeling very upset when something reminded you of the stressful experience?
      • 5. Having strong physical reactions when something reminded you of the stressful experience (eg, heart pounding, trouble breathing, sweating)?
      • 6. Avoiding memories, thoughts, or feelings related to the stressful experience?
      • 7. Avoiding external reminders of the stressful experience (eg, people, places, conversations, activities, objects, situations)?
      • 8. Trouble remembering important parts of the stressful experience?
      • 9. Having strong negative beliefs about yourself, other people, or the world (eg, "I am bad," "there is something seriously wrong with me," "no one can be trusted," "the world is completely dangerous")?
      • 10. Blaming yourself or someone else for the stressful experience or what happened after it?
      • 11. Having strong negative feelings such as fear, horror, anger, guilt, or shame?
      • 12. Loss of interest in activities that you used to enjoy?
      • 13. Feeling distant or cut off from other people?
      • 14. Trouble experiencing positive feelings (eg, being unable to feel happiness or have loving feelings for people close to you)?
      • 15. Irritable behavior, angry outbursts, or acting aggressively?
      • 16. Taking too many risks or doing things that could cause you harm?
      • 17. Being “superalert,” watchful, or on guard?
      • 18. Feeling jumpy or easily startled?
      • 19. Having difficulty concentrating?
      • 20. Trouble falling or staying asleep?
Indication
  • Screening assessment for PTSD; may be used for a provisional diagnosis
Interpretation of results
  • Scoring r15
    • 0: not at all
    • 1: a little bit
    • 2: moderately
    • 3: quite a bit
    • 4: extremely
    • An overall score of 33 is considered a positive provisional test result (based on initial validation study) r4

Differential Diagnosis

Most common

  • Adjustment disorders r1c152
    • Similar to PTSD, DSM-5-TR defines adjustment disorders as the presence of emotional or behavioral symptoms in response to identifiable stressor(s) occurring within 3 months of the onset of the stressor(s)
    • Unlike PTSD, the stressor can be of any severity or type
    • Diagnose adjustment disorder over PTSD in 1 of 2 situations:
      • When a patient is exposed to a stressor that meets criterion A for PTSD but responds in a way that does not meet all other PTSD criteria
      • When a patient responds in a way that meets all criteria for PTSD to a stressor that does not meet criterion A
  • Acute stress disorder r1c153
    • Similar to PTSD, acute stress disorder is a reaction to actual or threatened death, serious injury, or sexual violation resulting in symptoms related to intrusion, negative mood, dissociation, avoidance, and arousal, beginning or worsening after the stressful event(s)
    • Diagnostic criteria are slightly different from those of PTSD, requiring at least 9 symptoms from any of the following categories: intrusion, negative mood, dissociation, avoidance, and arousal
    • Differentiate by symptom duration; commonly diagnosed within 1 month after the traumatic event, when the symptom duration is not sufficient for PTSD diagnosis
  • Major depressive disorder r1c154d1
    • Mood disorder characterized by persistent feelings of sadness or hopelessness or loss of interest in activities once enjoyed
    • When preceded by a traumatic event, this condition may be mistaken for PTSD
    • Unlike PTSD, does not include any criteria B or C symptoms
    • Differentiate from PTSD by absence of several PTSD criteria symptoms
  • Personality disorder r1c155d2
    • Condition characterized by chronic, persistent (commonly since childhood or adolescence) impairments in personality functioning and pathologic personality traits
    • As with PTSD, patient may have difficulty maintaining interpersonal relationships
    • Differentiate by absence of readily identifiable actual or threatened death, serious injury, or sexual violation, linked to emergence of symptoms
  • Dissociative disorders r1c156
    • Disorders characterized by a loss of normal integration between memories, identity awareness and sensations, and body movements; include the following:
      • Dissociative amnesia r1c157
      • Dissociative identity disorder r1c158
      • Depersonalization-derealization disorder r1c159
    • Symptoms may be mistakenly classified as PTSD with dissociative symptoms r1
      • However, if all criteria for PTSD are met, then PTSD with dissociative symptoms should be diagnosed
    • Unlike PTSD, dissociative disorders do not always result from exposure to trauma r1
    • Differentiate from PTSD by absence of several PTSD criteria symptoms
  • Obsessive-compulsive disorder r1c160
    • Psychological condition characterized by recurrent intrusive thoughts or repetitive stereotyped behaviors that last for at least 1 hour per day or interfere with normal functioning
    • Similar to PTSD, obsessive-compulsive disorder is characterized by intrusive thoughts
    • However, in obsessive-compulsive disorder, thoughts do not typically relate to a past traumatic event
    • Differentiate from PTSD by the presence of compulsions, urges to perform rituals in response to obsessions, and absence of criteria D and E symptoms

Treatment

Goals

  • Reduce symptom severity r8
  • Prevent complications and development of comorbid conditions (eg, substance use disorder, depression) related to trauma r8
  • Improve functioning r8
  • Prevent relapse r8

Disposition

Admission criteria

  • Suicidal or homicidal ideation r8
  • Severe illness with lack of social support r8
  • Significant functional impairment r8

Recommendations for specialist referral

  • Refer to a mental health professional for definitive diagnosis and disease management r8
    • If managed in a primary care setting, the Veterans Administration/Department of Defense guideline recommends collaborative care to ensure that the veteran is receiving evidence-based care r4
  • Collaborate with a specialist in substance use disorders for patients with severe drug or alcohol dependence
  • Outpatient care is optimal for most patients; however, those with comorbid conditions may require inpatient care r8

Treatment Options

Consider patient preference when determining the best treatment plan r4

  • Engage in shared decision-making when deciding on a treatment plan, educating patients about effective, evidence-based treatment options and including them in the choice of treatment r4
  • Similar improvement in PTSD symptoms (posttraumatic stress disorder) was seen in treatment with sertraline (plus enhanced medication management), prolonged exposure therapy (plus placebo), and prolonged exposure therapy (plus sertraline) r20
  • Patients who receive their preferred treatment are more likely to adhere to treatment, overcome their PTSD diagnosis, and have fewer self-reported symptoms of PTSD, depression, and anxiety r21

Management can involve psychotherapy, pharmacotherapy, or both r8r20r22

  • Trauma-focused psychotherapy with exposure and/or cognitive restructuring components can constitute first line treatment r4r23
    • Meta-analysis supports use of such therapies over non–trauma-focused psychotherapy as first line intervention r24
    • Base choice of psychotherapy on clinical considerations, clinician expertise, and patient preference r4
      • The following trauma-focused psychotherapies have the most support from clinical trials: r4r5r25r26
        • Prolonged exposure therapy
          • Helps the patient to systematically approach, instead of avoid, safe (but feared) stimuli. Eventually the feared consequences are no longer expected and the automatic fear response to trauma-related stimuli subsides r9
          • Likely the most effective option; however, most often associated with discontinuation and higher dropout rates r27
        • Cognitive processing therapy (an approach that combines exposure therapy and cognitive therapy)
          • Focuses on interventions that directly target maladaptive thinking patterns r9
        • Eye movement desensitization and reprocessing
          • Effective component is likely related to exposure to trauma memories and not specific eye movements
    • Other psychotherapies with weaker evidence to recommend their use include specific cognitive behavioral therapies for PTSD, brief eclectic psychotherapy, narrative exposure therapy, and written exposure therapy r4
  • Pharmacotherapy
    • May be used as a first line or a second line treatment
      • Pharmacotherapy is a reasonable first line alternative to psychotherapy if the patient prefers it or if psychotherapies are not available r4r24r28
        • Sertraline, paroxetine, fluoxetine (selective serotonin reuptake inhibitors), and venlafaxine (serotonin-norepinephrine reuptake inhibitor) are recommended as monotherapies r5
          • Serotonin reuptake inhibitors reduce core symptoms of PTSD and improve associated depression and disability r28
            • Potential adverse effects include sexual dysfunction, increased sweating, gastrointestinal upset, and drowsiness or fatigue r4
          • Both sertraline and paroxetine are FDA approved for PTSD
            • Initial symptom improvement generally occurs within 2 to 4 weeks r8
            • In multicenter trial, sertraline was significantly better than placebo for improved avoidance-numbing symptoms cluster score, but not for reexperiencing score or for 12-week remission rate r29
            • Longer treatment (eg, 36 weeks as opposed to 12 weeks) improves treatment response r9
            • Patients with chronic disease may require a longer duration of treatment r8
          • Venlafaxine is effective compared with placebo r30
            • Significant improvement in avoidance-numbing and hyperarousal symptoms clusters; week 12 remission rate of 30.2% (significant compared with placebo) r29
        • Second line agents r23
          • Second-generation antipsychotic agents can be considered for reducing PTSD symptoms
            • May be used as monotherapy or as an adjunct to serotonin reuptake inhibitors or serotonin-norepinephrine reuptake inhibitors
          • There is conflicting evidence for the efficacy of prazosin, an α-adrenergic receptor antagonist, in treating PTSD-related sleep disturbances r31r32
            • No longer a preferred treatment
  • Combination therapy
    • When there is poor response to psychotherapy or a serotonin reuptake inhibitor, combination therapy is sometimes used. There is insufficient evidence to guide clinical decision-making on this approach; clinical judgment is required r4r33

Drug therapy

  • Selective serotonin reuptake inhibitors
    • Paroxetine r9c161
      • Paroxetine Hydrochloride Oral tablet; Adults: 20 mg PO once daily, initially. May increase the dose by 10 mg/day at intervals of at least 1 week if inadequate response and depending on tolerability. Max: 50 mg/day.
      • Paroxetine Hydrochloride Oral tablet; Older Adults: 10 mg PO once daily, initially. May increase the dose by 10 mg/day at intervals of at least 1 week if inadequate response and depending on tolerability. Max: 40 mg/day.
    • Sertraline r9c162
      • Sertraline Hydrochloride Oral tablet; Adults: 25 mg PO once daily initially. May increase the dose by 25 to 50 mg/day at intervals of at least 1 week if inadequate response and depending on tolerability. Usual dose: 50 to 200 mg/day. Max: 200 mg/day.
    • Fluoxetine r5c163
      • Fluoxetine Hydrochloride Oral capsule [Depression/Mood Disorders]; Adults: 10 to 20 mg PO once daily, initially. May increase the dose by 20 mg/day every 3 weeks if inadequate response and depending on tolerability. Max: 80 mg/day.
  • Serotonin norepinephrine reuptake inhibitors
    • Venlafaxine r4c164
      • Immediate release
        • Venlafaxine Hydrochloride Oral tablet; Adults: 25 mg PO 2 to 3 times daily, initially. May increase the dose if inadequate response and depending on tolerability. Dose range: 75 to 375 mg/day PO in 2 to 3 divided doses.
      • Extended release
        • Venlafaxine Hydrochloride Oral tablet, extended-release; Adults: 37.5 mg PO once daily, initially. May increase the dose if inadequate response and depending on tolerability. Dose range: 75 to 225 mg PO once daily.

Nondrug and supportive care

  • Educative and supportive care (most useful for managing the acute aftermath of a traumatic event) r8c165c166
    • Education should focus on the following:
      • Expected physiologic and emotional response to trauma
      • Strategies for decreasing secondary or continual exposure to trauma
      • Ways to reduce stress (eg, breathing, physical exercises)
      • Importance of remaining mentally active
      • Importance of self-care
  • Prolonged exposure therapy r9c167
    • Consists of 8 to 15 sessions for 60 to 90 minutes per session either weekly or biweekly
      • First few sessions focus on teaching the patient relaxation breathing exercises and providing psychoeducation about the symptoms of PTSD and the role of avoidance in maintaining treatment
      • Next several sessions focus on imaginal exposure, during which time the patient describes the traumatic event out loud for a prolonged time (eg, 30-45 minutes)
      • Includes in vivo exposure, which involves teaching the patient how to manage trauma-related situations that were previously avoided
      • Between sessions, patients are expected to listen to recordings of sessions and practice in vivo exposures
    • Treatment application should be culturally informed r8
    • Dropout rate ranges from 10% to 38% r9
  • Cognitive processing therapy r9c168
    • Typically 12 sessions in individual or group format
    • Similar to prolonged exposure therapy, includes psychoeducation and education about the role of avoidance in maintaining the disorder
    • Early in the process, the patient writes down and discusses the impact the traumatic event had on their life
    • Through discussion, the therapist probes the patient for potential maladaptive thinking patterns and helps to develop strategies for developing more effective thinking patterns
    • Dropout rates are approximately 20% r9
  • Eye movement desensitization and reprocessing r9c169
    • Length of treatment depends on patient ability to manage emotions
    • Initially, patients are trained to manage negative emotions
      • Patient is asked to list emotionally significant experiences and the distorted beliefs related to those experiences and desired beliefs
      • Patient is asked to think about a visual representation of the experience and to focus specifically on the physical sensations of the memory while engaging bilateral/saccadic eye movements
      • Patient then practices thinking the desired belief with the visual image of the trauma
  • Cognitive behavioral therapy r34c170c171
    • Consists of 12 to 16 sessions and may be in an individual or group format
      • May also be provided through a computer or mobile device facilitated by a therapist (internet-based cognitive behavioral therapy)
        • Some data suggest computer delivery may be as effective as in-person delivery r4
        • Expert opinion is divided owing to concerns of substantial selection bias in trials
    • Focuses on the relationship among the patient's thoughts, feelings, and behaviors with the goal of helping the patient maintain a sense of control and reducing avoidance behaviors
    • May include exposure to trauma narrative or reminders of the trauma and psychoeducation about how trauma may affect a person; may also include stress management techniques
  • Brief eclectic psychotherapy r35c172
    • Focuses on changing the patient's emotions to reduce shame and guilt and emphasizes the patient-therapist relationship
    • Consists of 16 weekly sessions for 45 minutes to 1 hour each
      • Therapy is initiated with psychoeducation and rationale for the therapy
      • First several sessions are focused on getting the patient to talk about the event in the present while being taught relaxation exercises
      • Final sessions are focused on exploring how the event has affected the patient and what can be learned from it
  • Narrative exposure therapy r36c173
    • Based on the patient establishing a chronologic narrative of their life, focusing on the traumatic event, but including positive experiences to contextualize memories of the trauma
    • Therapist concludes therapy by presenting the patient with a written biography of their life
    • Often used in community settings or for patients who experience a trauma related to political, cultural, or social forces r36

Comorbidities

  • Sleep disturbances c174
    • Present in nearly all veterans with PTSD r4c175
    • For patients with PTSD and insomnia, consider cognitive behavioral therapy for insomnia as first line treatment, with medication considered a second line intervention r4
    • Data are inconclusive for recommending a specific treatment for nightmares r4
  • Substance use disorders c176
    • Patients with PTSD and a substance use disorder (including nicotine/tobacco use disorder) can both tolerate and benefit from concurrent treatment for both conditions r4d3
    • Presence of a substance use disorder should not prevent concurrent treatment with evidence-based, trauma-focused therapy for PTSD r4
    • Combining medications and psychotherapy may be an effective strategy for treating PTSD and a co-occurring substance use disorder r4
  • Other mental disorders, including depression and anxiety disorders c177c178c179
    • Patients are 80% more likely to meet criteria for another mental disorder compared with those without PTSD; screen patients for these disorders r1
  • Traumatic brain injury c180
    • Among veterans deployed to the wars in Afghanistan and Iraq, co-occurrence of traumatic brain injury is 48% r1

Special populations

  • Older adults
    • Symptoms of disease may be exacerbated in this population by declining health, decreasing cognitive function, and social isolation r1
    • These patients may be reluctant to report traumatic events or admit to emotional or psychological problems

Monitoring

  • Monitor patient status throughout treatment
    • Monitor for appearance of, or changes in, destructive impulses toward self or others r8c181
      • For those with increased destructive impulses, consider inpatient care or more intensive treatment
    • Monitor treatment success
      • PTSD Checklist for DSM-5 (PCL-5) can be used for this purpose c182
        • 5- to 10-point change suggests reliable change after treatment has begun r15
      • Reevaluate treatment plan if patient develops new symptoms, there is significant deterioration in functional status, or condition does not respond to treatment for long periods r8

Complications and Prognosis

Complications

  • Children and adolescents
    • Problems in school or with peer relationships owing to irritable and/or aggressive behavior r1c183
    • Injury to self or others owing to reckless behavior c184c185
  • Adults
    • Social, occupational, or physical disability r1c186
      • Patients may lose their jobs owing to interference of symptoms with daily work or because of an inability to cope with reminders of the traumatic event(s) that they may face at work c187
      • Work absenteeism r1c188
      • Poor social relationships and family relationships, including social withdrawal c189c190c191
    • Secondary psychological disorders, such as:
    • Suicidal ideation and risk for suicide attempts r1c201c202
      • When assessing the patient, it is important to evaluate risk for suicide, including extent of planning for suicide, lethality of considered methods, and means for suicide r8
      • Patients who suffered childhood abuse may self-harm without the intention of suicide r8
      • Suicide risk is greater in patients with comorbid depression, substance use, panic attacks, and severe anxiety r8
    • Higher risk of somatization, chronic pain, and poor physical health c203c204c205

Prognosis

  • Duration of symptoms varies, with approximately 50% of patients recovering fully within 3 months, whereas others may experience symptoms for many years r1
  • Symptoms may recur with reminders of the original trauma or in other stressful circumstances r1
  • Interpersonal and intentional trauma (eg, torture, sexual assault) are associated with more severe or long-lasting disease r1
  • Discontinuation of selective serotonin reuptake inhibitors can lead to symptom relapse, regardless of the length of treatment r9
  • Sudden relapses may occur, even in patients previously determined to have a stable and positive clinical response to therapy; this is often due to events that reactivate traumatic concerns r8

Screening and Prevention

Screening

At-risk populations

  • Because of the availability of sound screening measures and the potential benefits of early identification of PTSD (posttraumatic stress disorder), the US Department of Veterans Affairs and Department of Defense recommend screening after separation from military service and during deployment r4
    • Department of Veterans Affairs recommends annual screening for the first 5 years after separation from service and every 5 years thereafter
    • Department of Defense recommends routine screening throughout cycles of deployment
    • A single screening is not recommended, because the disorder can have a fluctuating course, with periods of remission and recurrence
    • No screening method should be the sole basis for diagnosis; a more structured assessment is required

Screening tests

  • Primary Care PTSD Screen for DSM-5 (PC-PTSD-5) r14r19c206
    • 5-item questionnaire with "yes"/"no" responses r19
      • Have you ever experienced an especially frightening, horrible, or traumatic event; for example, a serious accident or fire, a physical or sexual assault or abuse, an earthquake or flood, a war, seeing someone be killed or seriously injured, or having a loved one die through homicide or suicide?
        • If the patient answers "yes," move on; if "no," then the test result is negative
      • In the past month, have you:
        • 1. Had nightmares about the event(s) or thought about the event(s) when you did not want to?
        • 2. Tried hard not to think about it or gone out of your way to avoid situations that reminded you of it?
        • 3. Been constantly on guard, watchful, or easily startled?
        • 4. Felt numb or detached from others, activities, or your surroundings?
        • 5. Felt guilty or unable to stop blaming yourself or others for the event(s) or any problems the event(s) may have caused?
      • Test result is positive if the patient answers "yes" to any 3 questions
        • Optimal sensitivity is reached if a 3-question cutoff is used
        • Optimal efficiency of the test is reached if a 4-question cutoff is used
  • PTSD Checklist for DSM-5 (PCL-5) r37c207
    • 20-item questionnaire
      • Questions:
        • In the past month, how much were you bothered by:
          • 1. Repeated, disturbing, and unwanted memories of the stressful experience?
          • 2. Repeated, disturbing dreams of the stressful experience?
          • 3. Suddenly feeling or acting as if the stressful experience were actually happening again (as if you were actually back there reliving it)?
          • 4. Feeling very upset when something reminded you of the stressful experience?
          • 5. Having strong physical reactions when something reminded you of the stressful experience (eg, heart pounding, trouble breathing, sweating)?
          • 6. Avoiding memories, thoughts, or feelings related to the stressful experience?
          • 7. Avoiding external reminders of the stressful experience (eg, people, places, conversations, activities, objects, situations)?
          • 8. Trouble remembering important parts of the stressful experience?
          • 9. Having strong negative beliefs about yourself, other people, or the world (eg, "I am bad," "there is something seriously wrong with me," "no one can be trusted," "the world is completely dangerous")?
          • 10. Blaming yourself or someone else for the stressful experience or what happened after it?
          • 11. Having strong negative feelings such as fear, horror, anger, guilt, or shame?
          • 12. Loss of interest in activities that you used to enjoy?
          • 13. Feeling distant or cut off from other people?
          • 14. Trouble experiencing positive feelings (eg, being unable to feel happiness or have loving feelings for people close to you)?
          • 15. Irritable behavior, angry outbursts, or acting aggressively?
          • 16. Taking too many risks or doing things that could cause you harm?
          • 17. Being “superalert,” watchful, or on guard?
          • 18. Feeling jumpy or easily startled?
          • 19. Having difficulty concentrating?
          • 20. Trouble falling or staying asleep?
      • Scoring
        • 0: not at all
        • 1: a little bit
        • 2: moderately
        • 3: quite a bit
        • 4: extremely
        • An overall score of 33 correlates well with the DSM-IV and DSM-5 diagnostic criteria; a score of 38 is considered to be more specific r4

Prevention

  • There are no prevention strategies for the general population c208
  • Limited evidence exists that trauma-focused psychotherapy in the emergency department within hours of trauma exposure may be beneficial r38c209
  • Indicated prevention is geared toward patients who have been exposed to trauma and have developed symptoms of acute stress disorder but have not (yet) developed PTSD
    • Brief trauma-focused psychotherapy is effective in reducing incidence of PTSD at 6 and 12 months r39r40c210
    • Pharmacotherapy with escitalopram was not shown to be effective in preventing PTSD r41r42c211
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