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## Complete Summary

#### GUIDELINE TITLE

VA/DoD clinical practice guideline for the management of post-traumatic
stress.

#### BIBLIOGRAPHIC SOURCE(S)

Veterans Health Administration, Department of Defense. VA/DoD clinical
practice guideline for the management of post-traumatic stress. Version
1.0. Washington (DC): Veterans Health Administration, Department of
Defense; 2004 Jan. Various p. \[479 references\]

#### GUIDELINE STATUS

This is the current release of the guideline.

### \*\* REGULATORY ALERT \*\*

#### FDA WARNING/REGULATORY ALERT

**Note from the National Guideline Clearinghouse**: This guideline
references a drug(s) for which important revised regulatory and/or
warning information has been released.

-   [December 12, 2007,
    Carbamazepine](http://www.fda.gov/medwatch/safety/2007/safety07.htm#carbamazepine):
    The U.S. Food and Drug Administration (FDA) has provided
    recommendations for screening that should be performed on specific
    patient populations before starting treatment with carbamazepine.

-   [May 2, 2007, Antidepressant
    drugs](http://www.fda.gov/medwatch/safety/2007/safety07.htm#Antidepressant):
    Update to the existing black box warning on the prescribing
    information on all antidepressant medications to include warnings
    about the increased risks of suicidal thinking and behavior in young
    adults ages 18 to 24 years old during the first one to two months of
    treatment.

-   [March 14, 2007, Sedative-hypnotic drug
    products](http://www.fda.gov/medwatch/safety/2007/safety07.htm#Sedative):
    Revisions to product labeling to include stronger language
    concerning potential risks including severe allergic reactions and
    complex sleep-related behaviors, such as sleep-driving.

### COMPLETE SUMMARY CONTENT

 \*\* REGULATORY ALERT \*\*\
 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 CONTRAINDICATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Post traumatic stress disorder

#### GUIDELINE CATEGORY

Diagnosis\
Evaluation\
Management\
Prevention\
Treatment

#### CLINICAL SPECIALTY

Family Practice\
Internal Medicine\
Psychiatry\
Psychology

#### INTENDED USERS

Health Care Providers\
Health Plans\
Hospitals\
Managed Care Organizations\
Nurses\
Physician Assistants\
Physicians\
Psychologists/Non-physician Behavioral Health Clinicians

#### GUIDELINE OBJECTIVE(S)

To survey best practices in post-traumatic stress disorder prevention,
diagnosis, and treatment and to determine whether the evidence supports
current practices, or whether the evidence suggests they should be
modified or discontinued

#### TARGET POPULATION

Any person who is eligible for care in the Veterans Affairs or
Department of Defense health care delivery system, specifically,
military men or women and veterans who have survived traumatic events

#### INTERVENTIONS AND PRACTICES CONSIDERED

**Initial Evaluation and Triage (includes Primary Prevention)**

1.  Education and training to promote hardiness and resiliency

    -   Provide realistic training

    -   Strengthen perceived ability to cope

    -   Create supportive interpersonal work environments

    -   Develop and maintain adaptive beliefs

    -   Develop workplace-specific comprehensive traumatic stress
        management programs

2.  Screen for Post-Traumatic Stress Disorder (PTSD) symptoms

    -   Primary care PTSD Screen

    -   PTSD Brief Screen

    -   Short Screening Scale for Diagnostic and Statistical Manual, 4th
        edition (DSM IV) PTSD

**Management of Acute Stress Reaction (ASR)**

1.  Screen for ASR

2.  Assess medical and functional status based on general appearance and
    screening instruments

3.  Medical status including:

    -   History, physical examination, and a neurological examination

    -   Use of prescribed medications, mood or mind-altering substances,
        and possible biological or chemical agent exposure

    -   A minimal mental status examination to assess cognitive function

    -   Screen for toxicology

    -   Radiological assessment of patients with focal neurological
        findings or possible head injury

    -   Appropriate laboratory studies to rule out medical disorders
        that may cause symptoms of acute stress reactions (e.g.,
        complete blood count \[CBC\], chemistry profile, thyroid
        studies, human chorionic gonadotropin \[HCG\],
        electrocardiogram, electroencephalogram)

    -   A focused psychosocial assessment

    -   Brief assessment of function

4.  Ensure basic physical needs are met by protecting, directing,
    connecting with, and triaging patients.

5.  Acute symptom management

    -   Assurance/reassurance

    -   Defusing (3-phased discussion provided within hours of the
        crisis for purpose of assessment triage and acute symptom
        mitigation)

    -   Mitigate fear and anxiety

    -   Sleep hygiene

    -   Re-establish routine

    -   Exercise and nutrition

    -   Bereavement

    -   Survivor success

    -   Advise about alcohol/substance use

    -   Modulate mood/irritability

6.  Psychological debriefing

7.  Facilitate social and psychological support

8.  Pharmacotherapy

    -   Propranolol

    -   Benzodiazepines

    -   Other sympatholytics

    -   Antidepressants

    -   Anticonvulsants

    -   Atypical antipsychotics

    -   Antihistamines

    -   Typical antipsychotics

9.  Reassessment after acute intervention by evaluation of risk factors

10. Referral and consultation with mental health professionals

**Management of Combat and Ongoing Operation Stress Reaction (COSR)**

1.  Screening for symptoms of COSR

2.  Assess risk of harm to self or others

3.  Identification of service members who can return to functioning in
    unit

4.  Acute symptom management according to \"PIES\" principle (proximity,
    immediacy, expectancy, simplicity)

5.  Transfer for treatment, as needed.

**Management of Acute Stress Disorder (ASD) and Post-Traumatic Stress
Disorder (PTSD) in Primary Care**

1.  Assessment of trauma exposure, trauma-related symptoms, and
    dangerousness to self or others

2.  Obtain medical history, physical examination, mental status
    examination, laboratory tests, psychosocial assessment, functional
    assessment, and other evaluations

3.  Patient education

4.  Referral to Vet Centers

**Management of Acute Stress Disorder (ASD) and Post-Traumatic Stress
Disorder (PTSD) in Specialty Care**

1.  Mental health assessment

2.  Medical history, physical examination, mental status examination,
    psychosocial assessment, and appropriate lab tests

3.  Documentation of DSM-IV criteria in medical record

4.  Patient and family education

5.  Initiation of therapy for PTSD

6.  Reassessment of status after therapeutic interventions

7.  Follow-up in mental health and referral

**Evidence-Based Intervention for Treatment of PTSD**

1.  Cognitive Therapy

2.  Exposure Therapy

3.  Stress Inoculation Testing

4.  Eye Movement Desensitization and Reprocessing

5.  Imagery Rehearsal Therapy

6.  Psychodynamic Therapy

7.  Group Therapy

8.  Dialectical Behavior Therapy

9.  Hypnosis

10. Spiritual Support

11. Acute Stress Disorder Pharmacotherapy

    -   Imipramine

    -   Propranolol

    -   Benzodiazepines

    -   Anticonvulsants

    -   Other antidepressants

    -   Other sympatholytics

    -   Atypical antipsychotics

    -   Choral hydrate

    -   Typical antipsychotics (not recommended)

12. Post-traumatic stress disorder pharmacotherapy using monotherapy
    and/or augmented therapy for targeted symptoms

    -   Selective serotonin reuptake inhibitors (SSRIs)

    -   Tricyclic antidepressants (TCAs)

    -   Monoamine oxidase inhibitors (MAOIs)

    -   Sympatholytics

    -   Novel antidepressants

    -   Anticonvulsants

    -   Atypical antipsychotics

    -   Buspirone

    -   Non-benzodiazepines hypnotics

    -   Benzodiazepines (not recommended)

    -   Typical antipsychotics (not recommended)

#### MAJOR OUTCOMES CONSIDERED

-   Effect of treatment on Clinician Administered Post-traumatic Stress
    Disorder Scale (CAPS) or other measures of post-traumatic stress
    disorder (PTSD)

-   Effect of treatment on symptoms of PTSD

-   Relapse rate in persons with PTSD

-   Prevention of PTSD

-   Risk factors for PTSD

-   Sensitivity and specificity of screening tools for PTSD

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Hand-searches of Published Literature (Primary Sources)\
Hand-searches of Published Literature (Secondary Sources)\
Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

The following three guidelines were identified by the Working Group as
appropriate seed guidelines. They served as the starting point for the
development of questions and key terms.

-   Effective Treatments for PTSD: Practice Guidelines from the
    International Society for Traumatic Stress Studies. Foa EB, Keane
    TM, Friedman MJ (Eds) 2000. New York: Guilford Publications

-   Expert Consensus Guideline Series: Treatment of Post-traumatic
    Stress Disorder. Foa EB, Davidson JRT, Francis A. J Clin Psychiatry
    1999; 60 (Suppl 16)

-   Mental Health and Mass Violence: Evidenced-Based Early Psychological
    Intervention for Victims/Survivors of Mass Violence. A Workshop to
    Reach Consensus on Best Practices. National Institute of Mental
    Health 2002. NIH Publication No. 02-5138. Washington, D.C.: U.S.
    Government Printing Office.
    <http://www.nimh.nih.gov/publicat/massviolence.pdf>

The Working Group developed eighteen researchable questions and
associated key terms after orientation to the seed guidelines and to
goals that had been identified by the Working Group. The questions
specified (adapted from the Evidence-Based Medicine (EBM) toolbox,
Centre for Evidence-Based Medicine,
([http://www.cebm.net](http://www.cebm.net/)):

-   Population -- characteristics of the target patient population

-   Intervention -- exposure, diagnostic, or prognosis

-   Comparison -- intervention, exposure, or control used for comparison

-   Outcome --outcomes of interest

These specifications served as the preliminary criteria for selecting
studies.

**Selection of Evidence**

Published, peer-reviewed, randomized controlled trials (RCTs) were
considered to constitute the strongest level of evidence in support of
guideline recommendations. This decision was based on the judgment that
RCTs provide the clearest scientifically sound basis for judging
comparative efficacy. The Working Group made this decision recognizing
the limitations of RCTs, particularly considerations of generalizability
with respect to patient selection and treatment quality. Meta-analyses
that included random controlled studies were also considered to be the
strongest level of evidence, as well as reports of evidence-based
systematic reviews.

A systematic search of the literature was conducted. It focused on the
best available evidence to address each key question and ensured maximum
coverage of studies at the top of the hierarchy of study types:
evidence-based guidelines, meta-analyses, and systematic reviews. When
available, the search sought out critical appraisals already performed
by others that described explicit criteria for deciding what evidence
was selected and how it was determined to be valid. The sources that
have already undergone rigorous critical appraisal include Cochrane
Reviews, Best Evidence, Technology Assessment, and Evidence-based
Practice Center (EPC) reports.

The search continued using well-known and widely available databases
that were appropriate for the clinical subject. In addition to
Medline/PubMed, the following databases were searched: Database of
Abstracts of Reviews of Effectiveness (DARE) and Cochrane Central
Register of Controlled Trials (CCTR). For Medline/PubMed, limits were
set for language (English), date of publication (1998 through July
2002), and type of research (RCT and meta-analysis). For most of the
pharmacotherapy topics the only limit was date, 1990 through March
2003).

Once definitive reviews or clinical studies that provided valid relevant
answers to the question were identified, the search ended. The search
was extended to studies/reports of lower quality (observational studies)
only if there were no high quality studies.

Exclusion criteria included reviews that omitted clinical course or
treatment. Some retrieved studies were rejected on the basis of
published abstracts, and a few were rejected after the researchers
scanned the retrieved citation for inclusion criteria. Typical
exclusions included studies involving children and adolescents.

The results of the search were organized and reported using reference
manager software. At this point, additional exclusion criteria were
applied. The bibliographies of the retrieved articles were hand-searched
for articles that may have been missed by the computer search.
Additional experts were consulted for articles that may also have been
missed.

**Literature Review and Inclusion Criteria**

The articles identified during the literature reviews formed the basis
for formulating the guideline recommendations. The literature search for
the guideline development was validated by: (1) comparing the results to
a search conducted by the independent research and appraisal team; (2) a
review of the database by the expert panel; and (3) requesting articles
pertaining to special topics from the experts in the working group.

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Expert Consensus\
Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

The following rating schemes are from the U.S. Preventive Services Task
Force (USPSTF) (2001).

**Quality of Evidence (QE)**

**I** At least one properly done randomized controlled trial (RCT)\
**II-1** Well designed controlled trial without randomization\
**II-2** Well designed cohort or case-control analytic study\
**II-3** Multiple time series, dramatic results of uncontrolled
experiment\
**III** Opinion of respected authorities, case reports, and expert
committees

**Overall Quality**

**Good**: High grade evidence (I or II-1) directly linked to health
outcome\
**Fair**: High grade evidence (I or II-1) linked to intermediate outcome
or moderate grade evidence (II-2 or II-3) directly linked to health
outcome\
**Poor**: Level III evidence or no linkage of evidence to health outcome

**Net Effect of the Intervention**

**Substantial**: More than a small relative impact on a frequent
condition with a substantial burden of suffering; *or* a large impact on
an infrequent condition with a significant impact on the individual
patient level

**Moderate**: A small relative impact on a frequent condition with a
substantial burden of suffering; *or* a moderate impact on an infrequent
condition with a significant impact on the individual patient level

**Small**: A negligible relative impact on a frequent condition with a
substantial burden of suffering; *or* a small impact on an infrequent
condition with a significant impact on the individual patient level

**Zero or Negative**: Negative impact on patients; *or* no relative
impact on either a frequent condition with a substantial burden of
suffering; or An infrequent condition with a significant impact on the
individual patient level

#### METHODS USED TO ANALYZE THE EVIDENCE

Review of Published Meta-Analyses\
Systematic Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

**Preparation of Evidence Tables (reports)**

A group of clinician reviewers and other researchers in health care with
experience in evidence-based appraisal independently read and coded each
article that met inclusion criteria. Each article was turned into a
one-page summary of the critical appraisal by the research team and
added to a central electronic database. Clinicians from the Center for
Evidence-Based Practice at the State University of New York \[SUNY\],
Upstate Medical University, Department of Family Medicine contributed
several of the appraisal reports. Each of the evidence reports covered:

-   Summary of findings

-   Methodology

-   Search terms

-   Resources searched

-   Summary table of findings

-   Critical appraisal of each study

Evidence-based practice involves integrating clinical expertise with the
best available clinical evidence derived from systematic research. The
Working Group reviewed the evidence and graded it using the rating
scheme developed by the United States Preventive Service Task Force
(USPSTF) (2001). The experts themselves, after an orientation and
tutorial on the evidence grading process, formulated Quality of Evidence
ratings, a rating of Overall Quality, a rating of the Net Effect of the
Intervention (see \"Rating Scheme for the Strength of the Evidence\"),
and an overall Recommendation (see \"Rating Scheme for the Strength of
the Recommendations\").

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

The development of the Veterans Affairs/Department of Defense (VA/DoD)
Clinical Practice Guideline for the Management of Traumatic Stress
Symptoms was initiated in May 2002 and continued through May 2003. The
development process followed the steps described in \"Guideline for
Guidelines\" an internal working document of Veterans Health
Administration´s National Clinical Practice Guideline Council, which
requires an ongoing review of the work in progress.

The Offices of Quality and Performance and Patient Care Service, in
collaboration with the network Clinical Managers, the Deputy Assistant
Under Secretary for Health, and the Medical Center Command of the DoD
identified clinical leaders to champion the guideline development
process. During a preplanning conference call, the clinical leaders
defined the scope of the guideline and identified a group of clinical
experts from the VA and DoD that formed the Guideline Development
Working Group.

The Working Group participated in several face-to-face sessions to reach
a consensus about the guideline recommendations and to prepare a draft
document. The draft was revised by the experts through numerous
conference calls and individual contributions to the document.

The majority of the literature supporting the science for these
guidelines is referenced throughout the document and is based upon key
randomized controlled trials and longitudinal studies published from
1998 through July 2002. Following the independent review of the
evidence, a consensus meeting was held to discuss discrepancies in
ratings and formulate recommendations. Where existing literature was
ambiguous or conflicting, or where scientific data was lacking on an
issue, recommendations were based on the clinical experience of the
Working Group. These recommendations are indicated in the evidence
tables as based on \"Working Group Consensus\".

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

The following rating scheme is from the U.S. Preventive Services Task
Force (USPSTF) (2001). The Task Force uses its assessment of the
evidence and magnitude of net benefit to make a recommendation.

**A** A strong recommendation that the intervention is always indicated
and acceptable\
**B** A recommendation that the intervention may be useful/effective\
**C** A recommendation that the intervention may be considered\
**D** A recommendation that a procedure may be considered not
useful/effective, or may be harmful\
**I** Insufficient evidence to recommend for or against -- the clinician
will use clinical judgment

#### COST ANALYSIS

In a presentation to the United States Food and Drug Administration
(FDA), one study quantified some of the costs of post-traumatic stress
disorder (PTSD) to patients and to the health care system:

-   Early outcome studies show that early diagnosis and appropriate
    treatment of trauma-related disorders are cost effective, especially
    when compared with the cost of incorrect or inadequate treatment
    occurring prior to a correct diagnosis.

-   In one study of women with trauma related dissociative disorders, if
    a correct diagnosis had been made after 12 months of treatment,
    rather than after an average of 99 months of treatment, the
    estimated savings would have been \$250,000 per patient.

-   In a study of rape victims, severely victimized female members in a
    Health Maintenance Organization (HMO) had outpatient medical
    expenses double those of control HMO members.

-   Findings suggest that from 3.1 to 4.7 million crime victims received
    mental health treatment in 1991, for an estimated total cost of
    \$8.3 to \$9.7 billion. These recipients represent only a small
    portion of trauma victims in need of treatment, since those with
    PTSD are typically reluctant to seek professional help.

#### METHOD OF GUIDELINE VALIDATION

Clinical Validation-Trial Implementation Period\
External Peer Review\
Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

The final draft was reviewed by mental health and primary care experts
in the Department of Veterans Affairs (VA) and Department of Defense
(DoD). Their feedback was integrated into the final draft. Nonetheless,
this document is a work in progress. It will be updated every two years,
or when significant new evidence is published.

Parts of the Clinical Practice Guideline have already served in
Afghanistan and Iraq.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

The recommendations for the management of post-traumatic stress are
organized into 5 major algorithms. The algorithms, the objectives, and
recommendations that accompany them, and the evidence supporting the
recommendations are presented below. The quality of evidence (I, II-1,
II-2, II-3, III), overall quality (Good, Fair, Poor), net effect of
intervention (Substantial, Moderate, Small, Zero Or Negative), strength
of recommendation grading (A-D, I) are defined at the end of the \"Major
Recommendations\" field.

*Note: A list of abbreviations is provided at the end of the \"Major
Recommendations\" field*.

CORE MODULE - INITIAL EVALUATION AND TRIAGE

**Primary Prevention**

A.  **Education And Training to Promote Hardiness and Resiliency**

> *Objective*
>
> Prepare individuals and groups for exposure to traumatic experiences
> in ways that minimize the likelihood of development of post traumatic
> stress disorder (PTSD) and other trauma-related problems.
>
> *Recommendations*

1.  In high-risk occupations for which probability of trauma exposure is
    moderate or high, efforts should be undertaken to increase
    psychological resilience of workers to the negative effects of
    trauma exposure. (Working Group Consensus) (**Quality of Evidence
    \[QE\] -- III, Overall Quality -- Poor, Recommendation \[R\]-- I**)

**Populations At-Risk For Developing PTSD**

B.  **People At-Risk For Developing Stress Symptoms After Trauma**

> *Objective*
>
> Identify persons at risk for developing a traumatic stress disorder
> (PTSD) after trauma exposure.
>
> *Recommendations*

1.  Persons exposed to trauma should be assessed for known risk factors
    for developing PTSD -- both pre-trauma risks and post-trauma risks.
    (Brewin, Andrews, & Valentine, 2000) (**QE -- II, Overall Quality --
    Good, R -- B**)

2.  The trauma type, nature, and severity should be assessed. (Brewin et
    al., 1999; Bryant et al., 2000; Harvey & Bryant, 2000; Mellman et
    al., 2001) (**QE -- II, Overall Quality -- Good, R - B**)

3.  Assessment of existing social supports and ongoing stressors is
    important. (Litz et al., 2002) (**QE -- II, Overall Quality -- Good,
    R -- B**)

4.  Patients with Acute Stress Disorder (ASD) warrant careful clinical
    attention, as they are at high-risk for developing PTSD. (Birmes et
    al., 2001; Brewin et al., 1999; Bryant et al., 2000, Harvey &
    Bryant, 2000; Mellman et al., 2001; Murray, Ehlers, & Mayou, 2002)
    (**QE -- II, Overall Quality -- Good, R -- B**)

5.  Patients with dissociative symptoms may also warrant careful
    clinical attention. (Brewin et al., 1999; Murray, Ehlers, & Mayou,
    2002)(**QE-- II, Overall Quality -- Fair, R -- C**)

**Secondary Prevention -- Surveillance Screening**

C.  **Screen For PTSD Symptoms**

> *Objective*
>
> Identify possible cases of PTSD.
>
> *Recommendations*

1.  All new patients should be screened for symptoms of PTSD (Breslau et
    al., \"Previous exposure,\" 1999; Leskin & Westrup, 1999; Prins et
    al. 1999; Taubman-Ben-Ari et al., 2001) (**QE -- II-2, Overall
    Quality -- Fair, R -- B**) initially and then on an annual basis or
    more frequently if clinically indicated due to clinical suspicion,
    recent trauma exposure (e.g., major disaster), or history of
    PTSD.(Working Group Consensus) (**QE -- III, Overall Quality --
    Poor, R -- I**)

2.  Patients should be screened for symptoms of PTSD using paper and
    pencil or computer-based screening tools.

3.  No studies are available that compare the benefits of one PTSD
    screening tool versus another. However, the following screening
    tools have been validated and should be considered for use:

    -   Primary Care PTSD Screen (PC-PTSD)

    -   PTSD Brief Screen

    -   Short Screening Scale for DSM IV PTSD

> (Breslau et al. \"Previous exposure,\" 1999; Leskin & Westrup, 1999;
> Prins et al., 1999) (**QE -- II-2, Overall Quality -- Fair, R -- B**)

4.  There is, as yet, insufficient evidence to recommend special
    screening or differing PTSD treatment for members of any cultural or
    racial groups. (Frueh, Brady & de Arellano , 1998; Frueh et al.,
    1997; Frueh, Smith, & Libet, 1996; Ortega & Rosenheck, 2000; Penk et
    al., 1989; Rosenheck & Fontana, 1996; Trent et al., 2000) (**QE --
    III, Overall Quality -- Poor, R -- I**)

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D.  **Are Trauma Related Symptoms Present?**

> *Objective*
>
> Identify people exposed to trauma who are at risk for developing an
> acute stress reaction (ASR), acute stress disorder (ASD), or
> post-traumatic stress disorder (PTSD).
>
> *Recommendations*

1.  Individuals who are presumed to have symptoms of PTSD or who are
    positive for PTSD on the initial 4-item screening should receive
    specific assessment of their symptoms.

2.  Useful information may include details such as time of onset,
    frequency, course, severity, level of distress, functional
    impairment, and other relevant information.

3.  The elapsed time since the exposure to trauma is very important in
    assessing the risk of developing PTSD and determining the
    appropriate intervention. See the original guideline document for
    definitions of stress-related disorders and syndromes that will help
    providers select the appropriate treatment algorithm.

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E.  **Normalization For Asymptomatic Survivors And Responders**

> *Objective*
>
> Help trauma survivors and responders who are NOT themselves
> experiencing signs or symptoms recognize that these reactions in
> others are common in the aftermath of trauma and do not signify
> personal inadequacy, health problems, mental illness, or other
> enduring negative consequences.
>
> *Recommendations*

1.  Pre- and post-trauma education should include helping asymptomatic
    trauma survivor or responder understand that the acute stress
    reactions of other people are common and do not indicate personal
    failure or weakness, mental illness, or health problems. The
    responders should be taught the simple words and measures that will
    support quick recovery, rather than push survivors towards a
    persisting disorder. (Working Group Consensus); (**QE -- III,
    Overall Quality Poor, R - I**)

2.  Education should include sufficient review of the many ways that
    post-traumatic problems can present, including symptoms in the
    ASD/PTSD spectrum, behavioral problems with family and friends,
    occupational problems, and alcohol or other substance misuse/abuse.

3.  Provide education and access information to include the following:

    -   Begin with clear statement about ASR being normal, common, and
        expectable responses to trauma; the reliance on self and buddy
        management, and other available resources if stress symptoms
        persist or worsen.

    -   Maximize positive expectation of mastery.

    -   Demystify PTSD (before listing symptoms) and emphasize the human
        brain and mind´s natural resiliency (e.g., our
        forefathers/mothers, generations ago survived very bad
        situations or we wouldn´t be here, and we can survive also).

    -   Painful memories sometimes get stuck, through no fault of the
        sufferer. Such memories cause real biological changes that can
        cause physical change and illness elsewhere in the body. Many of
        these changes can be reversed. All can be compensated for by
        developing new brain skills, aided by medication when
        appropriate.

    -   Professionals with special skills and capabilities (including
        some religious pastors and mental health professionals, other
        medical people, and others with special training and
        supervision) can intervene to reverse this process.

    -   Resolving developing symptoms and problems

MODULE A1 - ACUTE STRESS REACTION (ASR)

**Assessment**

A.  **Trauma Exposure**

> *Definition*
>
> Traumatic events are events that cause a person to fear that he or she
> may die or be seriously injured or harmed. These events also can be
> traumatic when the person witnesses them happening to others. Such
> events often create feelings of intense fear, helplessness, or horror
> for those who experience them. Among the common kinds of traumatic
> events are:

-   Combat in a war zone

-   Rape or other sexual assault

-   Natural disaster (e.g., hurricanes, floods, or fires)

-   Child physical and/or sexual abuse

-   Domestic violence (battering)

-   Motor vehicle accidents

-   Exposure to the sudden or unexpected death of others

-   Sudden life-threatening physical illness (e.g., heart attack or
    cancer)

B.  **Screen For ASR**

> *Objective*
>
> Identify individuals who may be at risk for endangering themselves or
> others due to emotional distress or functional incapacity.
>
> *Recommendations*

1.  Identification of a patient with ASR symptoms is based on
    observation of behavior and function.

2.  There is no evidence to support any specific screening tool.

3.  Individuals exhibiting the following responses to trauma should be
    screened for ASR:

    -   Physical: exhaustion, hyperarousal, somatic complaints
        (gastrointestinal \[GI\], genitourinary \[GU\], musculoskeletal
        \[MS\], cardiovascular \[CV\], respiratory, nervous system
        \[NS\]), conversion disorder symptoms

    -   Emotional: anxiety, depression, guilt/hopelessness

    -   Behavioral: avoidance, problematic substance use

    -   Cognitive/mental: amnestic or dissociative symptoms,
        hypervigilance, paranoia, intrusive re-experiencing.

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C.  **Dangerousness To Self Or Others**

> *Objective*
>
> Protect individuals who may be at risk for endangering themselves or
> others due to emotional distress or functional incapacity.
>
> *Recommendations*

1.  Acute medical issues should be addressed to preserve life and avoid
    further harm:

    -   ABC´s (Maintain: Airways, Breathing, Circulation)

    -   Substance intoxication or withdrawal

    -   Danger to self or others: suicidal, homicidal behavior

    -   Self-injury or mutilation

    -   Inability to care for oneself

2.  A safe private, and comfortable environment should be arranged for
    continuation of the evaluation.

    -   Establish a working treatment alliance with the patient

    -   Maintain a supportive, nonblaming nonjudgmental stance
        throughout the evaluation

    -   Help with the removal of any ongoing traumatic event

    -   Minimizing further traumas that may arise from the initial
        traumatic event

    -   Assess and optimize social supports

3.  Legal mandates should be followed:

    -   Reporting of violence, assault

    -   Confidentiality for the patient

    -   Mandatory testing

    -   Attend to chain of evidence in criminal cases (e.g., rape,
        evaluation)

    -   Involuntary Commitment procedures if needed

4.  Carefully consider the following potential interventions to secure
    safety:

    -   Find safe accommodation and protecting against further trauma

    -   Voluntary Admission

    -   Restraint/seclusion only if less restrictive measures are
        ineffective

    -   Forced medications

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D.  **Assess Medical and Functional Status Based on General Appearance
    and Screening Instruments**

> *Recommendations*

1.  Medical status should be obtained for all persons presenting with
    symptoms to include:

    -   History, physical examination, and a neurological examination

    -   Use of prescribed medications, mood or mind-altering substances,
        and possible biological or chemical agent exposure

    -   A minimal mental status examination to assess cognitive function

2.  The history and physical examination findings should lead the
    provider to other assessments as clinically indicated. There is no
    test for acute stress reaction, so testing is directed towards
    detection of associated medical conditions. Assessment may include:

    -   Screen for toxicology if the symptom presentation indicates

    -   Radiological assessment of patients with focal neurological
        findings or possible head injury

    -   Appropriate laboratory studies to rule out medical disorders
        that may cause symptoms of acute stress reactions (e.g.,
        complete blood count \[CBC\], chemistry profile, thyroid
        studies, human choriogonadotropin \[HCG}, electrocardiogram
        \[EKG\], electroencephalography \[EEG\])

3.  A focused psychosocial assessment should be performed including
    active stressors, losses, current social supports, basic needs (e.g.
    housing, food, financial resources).

4.  A brief assessment of function based on general appearance and
    behavior should be completed to evaluate: 1) objectively impaired
    function; 2) subjectively impaired function; 3) baseline level of
    function (LOF) vs. current LOF; and 4) family and relationship
    functioning.

> The approach to triage in the immediate response to traumatic exposure
> for service members with symptoms during Ongoing Military Operations
> may vary markedly from the management of civilians exposed to
> traumatic events. Combat and Operational Stress Reactions (COSR)
> management is targeted to preserve the fighting force and return the
> service member (SM) to functional status.
>
> See module A2 - Management of Combat and Operational Stress Reaction
> (COSR)

E.  **Assess Preexisting Psychiatric And Medical Conditions**

> *Recommendations*

1.  Assessment of patients with preexisting psychiatric conditions to
    identify the vulnerable, high-risk individuals and groups

2.  Referral to mental health specialty when indicated or emergency
    hospitalization if needed

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F.  **Risk Factors For Developing ASD/PTSD**

> *Recommendations*

1.  Individuals exposed to trauma should be screened for one or more of
    the following risk factors for developing ASD/PTSD.

> [Pre-traumatic factors]{.underline}:

-   Ongoing life stress

-   Lack of social support

-   Preexisting psychiatric disorder

-   Other pre-traumatic factors including: female gender, low
    socioeconomic status, lower level of education, lower level of
    intelligence, race (Hispanic, Japanese, other ethnic minority),
    reported abuse in childhood, report of other previous
    traumatization, report of other adverse childhood factors, family
    history of psychiatric disorders, poor training or preparation for
    the traumatic event

> [Peri-traumatic or trauma related factors]{.underline}:

-   Severe trauma

-   Type of trauma (interpersonal traumas such as torture, rape, or
    assault convey high risk of PTSD)

-   High perceived threat to life

-   Age at trauma (school age youth, 40--60 years of age)

-   Community (mass) trauma

-   Other peri-traumatic factors including: history of peri-traumatic
    dissociation and interpersonal trauma

> [Post-traumatic factors]{.underline}:

-   Ongoing life stress

-   Lack of social support

-   Bereavement

-   Major loss of resources

-   Other post-traumatic factors including children at home and female
    with distressed spouse

**Triage And Treatment**

G.  **Ensure Basic Physical Needs Are Met**

> *Objective*
>
> Ensure trauma-exposed persons with acute stress symptoms have their
> basic needs met.
>
> *Recommendations*

1.  Acute intervention should ensure that the following needs are met:

> [Basic Needs]{.underline}:

-   Safety/security/survival

-   Food, hydration, clothing, and shelter

-   Sleep

-   Medication (i.e., replace medications destroyed/lost)

-   Orientation

-   Communication with family, friends, and community

-   Protection from ongoing threats/toxins/harm

> [Psychological First Aid]{.underline}:

-   Protect survivors from further harm

-   Reduce physiological arousal

-   Mobilize support for those who are most distressed

-   Keep families together and facilitate reunion with loved ones

-   Provide information, foster communication and education

-   Use effective risk communication techniques

H.  **Acute Symptom Management**

> *Recommendations*

1.  Symptoms treatment should be provided after basic needs are met
    (e.g., sleep, normalization, and other nonpharmacological
    modalities).

2.  Apply a series of specific psychological interventions (individually
    or in a group) to reduce acute stress symptoms and to address both
    general recovery and specific symptoms (e.g., breathing/relaxation
    treatment). Individual psychological interventions may include:

    -   Assurance/reassurance

    -   Defusing (3-phased discussion provided within hours of the
        crisis for purpose of assessment triage and acute symptom
        mitigation)

    -   Mitigate fear and anxiety

    -   Sleep hygiene

    -   Reestablish routine

    -   Exercise and nutrition

    -   Bereavement

    -   Survivor success

    -   Advise about alcohol/substance use

    -   Modulate mood/irritability

> Group psychological interventions:

-   Groups may be effective vehicles for providing trauma-related
    education, training in coping skills, and increasing social support
    especially in the context of multiple group sessions.

-   Group participation should be voluntary.

3.  Peoples´ reaction to ASR varies. Some want and feel a need to
    discuss the event, and some have no such need. Respect individual
    and cultural preferences in the attempt to meet their needs as much
    as possible. Allow normal recovery, and monitor.

4.  Consider a short course of medication for some individuals targeted
    for specific symptoms (e.g., sleep disturbance). \[See Annotation M
    \]

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I.  **Psychological Debriefing**

> *Objective*
>
> Reduce risk for development of PTSD following traumatic event.
>
> *Recommendation*
>
> [Individual]{.underline}:

1.  Recommend against psychological debriefing as a viable means of
    reducing acute post-traumatic distress (ASR or ASD) or progression
    to PTSD. (Hobbs et al., 1996; Mayou, Ehlers, & Hobbs, 2000; Bisson
    et al., 1997)(**QE -- I, Overall Quality -- Fair, Strength of R --
    D**)

> [Group]{.underline}:

1.  There is insufficient evidence to recommend for or against
    conducting structured group debriefing.

2.  Compulsory repetition of traumatic experiences in a group may be
    counterproductive.

3.  Group debriefing with preexisting groups (teams, units, Emergency
    Medical Teams \[EMTs\], co-workers, family members) may assist with
    group cohesion, morale, and other important variables that have not
    been demonstrated empirically. (Foa, Keane, & Friedman, 2000; Rose,
    Bisson, & Wessely, 2002) (**QE -- III, Overall Quality -- Poor,
    Strength of R -- I**)

4.  Group participation should be voluntary.

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J.  **Education and Normalization / Expectancy Of Recovery**

> *Recommendation*

1.  All survivors should be given educational information to help
    normalize common reactions to trauma, improve coping, enhance
    self-care, facilitate recognition of significant problems, and
    increase knowledge of and access to services. Such information can
    be delivered in many ways, including public media, community
    education activities, and written materials.

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K.  **Facilitate Social and Spiritual Support**

> *Recommendation*

1.  Preserve an interpersonal safety zone protecting basic personal
    space (e.g., privacy, quiet, personal effects).

2.  Provide nonintrusive ordinary social contact (e.g., a \"sounding
    board,\" judicious use of humor, small talk about current events,
    silent companionship).

3.  Provide opportunities for grieving for losses. Provide access to
    religious/spiritual resources when sought. (Providing space and
    opportunities for prayers, mantras, rites and rituals, and
    end-of-life care as determined important by the patient)

4.  Consider providing direct spiritual care or ensuring patient access
    to spiritual care when sought.

> *Evidence*

1.  Consider referral for religious/spiritual counseling as indicated
    for patient symptoms, consistent with available resources, and
    resonant with patient belief systems (Baldacchino & Draper, 2001;
    Bell Meisenhelder, 2002; Calhoun et al., 2000; Humphreys et al.,
    2001; Nixon et al., 1999; Strawbridge et al., 1998) (**QE -- III,
    Overall Quality -- Poor, R -- I**)

2.  When providing psychological first aid or primary care services,
    consider providing direct spiritual care or ensuring patient access
    to spiritual care (Bogia & Preston, 1985; Everly, \"The role of
    pastoral crisis,\" 2000) (**QE -- II**, **Overall Quality -- Fair, R
    -- C**)

3.  For patients who have developed PTSD, consider referral for
    religious/spiritual counseling as indicated for patient symptoms,
    consistent with available resources, and resonant with patient
    belief systems (Baldacchino & Draper, 2001; Bell Meisenhelder, 2002;
    Calhoun et al., 2000; Humphreys et al., 2001; Nixon et al., 1999;
    Strawbridge et al., 1998) (**QE -- III, Overall Quality -- Poor, R
    -- I**)

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L.  **Pharmacotherapy**

> *Objective*
>
> To lessen the physical, psychological, and behavioral morbidity
> associated with acute stress reaction, hasten the return to full
> function (duty), and diminish the likelihood of chronicity
>
> *Recommendations*
>
> **Summary Table -- Pharmacotherapy for ASR**

  -------------------------------------------------------------------------------
  **R\***   **Significant   **Some Benefit**  **Unknown**        **No
            Benefit**                                            Benefit/Harm**
  --------- --------------- ----------------- ------------------ ----------------
  **A**                                                           

  **B**                     Propranolol                           

  **C**                                                           

  **I**                     Benzodiazepines   Other               
                                              aympatholytics\    
                                              Antidepressants\   
                                              Anticonvulsants\   
                                              Atypical           
                                              antipsychotics\    
                                              Antihistamines     

  **D**                                                          Typical
                                                                 antipsychotics
  -------------------------------------------------------------------------------

> \*R = Level of recommendation

1.  Strongly recommend providing for physical needs, sleep,
    normalization, and other non-pharmacological modalities.

2.  Recommend the use of medication only for individuals that do not
    respond to non-pharmacological treatment as a normal recovery is
    expected from ASR.

3.  Consider a short course of medication targeted for specific
    symptoms.

    -   Sleep disturbance/insomnia (e.g., benzodiazepines,
        antihistamines)

    -   Hyperarousal/excessive arousal/panic attacks. (e.g.,
        benzodiazepines, propranolol \[up to 10 days\])

4.  There is insufficient evidence to support a recommendation for
    preventative use of a pharmacological agent to prevent the
    development of ASD or PTSD.

> *Evidence*

1.  Benzodiazepines (Mellman, Byers, & Augenstein, 1998)(**QE \-- III ,
    Overall Quality -- Poor, Net Effect -- Moderate, R -- I**)

2.  Antihistamines (**QE -- III, Overall Quality \-- Poor, Net Effect --
    Small, R -- I**)

3.  Propranolol (Pitman et al., 2002) (**QE -- I, Overall Quality --
    Good, Net Effect \-- Moderate, R -- B**)

4.  Pharmacotherapy prophylaxis for ASD or PTSD (Stein et al., 2000)
    (**QE -- I, Overall Quality -- Poor, Net Effect \-- Small, R -- I**)

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M.  **Reassessment**

> *Objective*
>
> Identify patients with persistent traumatic stress symptoms, related
> dysfunction, or additional treatment needs.
>
> *Recommendations*

1.  Treatment response to the acute intervention should be reassessed.
    This should include an evaluation for the following risk factors:

    -   Persistent or worsening traumatic stress symptoms (e.g.,
        dissociation, panic, autonomic arousal, cognitive impairment)

    -   Significant functional impairments (e.g. role/work,
        relationships)

    -   Dangerousness (suicidal or violent ideation, plan, and/or
        intent)

    -   Severe psychiatric comorbidity (e.g., psychotic spectrum
        disorder, substance use disorder or abuse)

    -   Maladaptive coping strategies (e.g., pattern of impulsivity,
        social withdrawal under stress)

    -   New or evolving psychosocial stressors

    -   Poor social supports

2.  Follow-up after acute intervention to determine patient status.

    -   Patient does not improve or status worsens -- refer to mental
        health provider and/or PTSD specialty team. Recommend continued
        involvement of the primary care provider in the treatment.
        Patients with multiple problems may benefit from a
        multi-disciplinary approach to include occupational therapy,
        spiritual counseling, recreation therapy, social work,
        psychology, and/or psychiatry.

    -   Patient demonstrates partial improvement (e.g., less arousal,
        but no improvement in sleep) -- consider augmentation or
        adjustment of the acute intervention within 2 weeks.

    -   Patient recovers from acute symptoms -- provide education about
        acute stress reaction and contact information with instructions
        for available follow-up if needed.

**Follow-up**

N.  **Referral And Consultation With Mental Health**

> *Objective*
>
> Provide guidance for primary care providers on optimal referral for
> potential PTSD patients.
>
> *Recommendations*

1.  Individuals who exhibit any of the following conditions should be
    referred to mental health:

    -   Failure to respond to acute supportive interventions

    -   Worsening of stress related symptoms

    -   High potential for dangerousness

    -   Development of ASD/PTSD

    -   New onset of dangerousness or maladaptive coping to stress

    -   Exacerbation of pre existing psychiatric conditions

    -   Deterioration in function

    -   New onset stressors, poor social supports, or inadequate coping
        skills.

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O.  **Monitor And Follow-Up**

> *Recommendations*

1.  Follow-up should be offered to those individuals who request it.

2.  Follow-up should be offered to individuals and groups at high risk
    of developing adjustment difficulties following exposure to major
    incidents and disasters, including individuals who:

    -   Have ASD or other clinically significant symptoms stemming from
        the trauma

    -   Are bereaved

    -   Have a preexisting psychiatric disorder

    -   Have required medical or surgical attention

    -   Were exposed to a major incident or disaster that was
        particularly intense and of long duration

MODULE A2 - COMBAT AND ONGOING OPERATION STRESS REACTION (COSR)

***The approach to triage in the immediate response to traumatic
exposure for service members with symptoms during Ongoing Military
Operations is directed by dual sets of objectives***:

**Military Considerations**

Management of combat and operational stress reactions (COSR) during
ongoing military operations is targeted to preserve the fighting force
and return the service member (SM) to functional status. Context and
setting of care delivery may vary markedly.

**Military Clinical Objectives**

1.  Prevent exacerbation of symptoms/mitigate symptoms of acute stress

2.  Prevent development of traumatic stress sequelae (e.g., ASD, PTSD,
    depressive disorders, anxiety disorders, and substance use
    disorders)

3.  Keep SM with his/her unit and prevent unnecessary medical evacuation

4.  Return SM to duty as soon as possible

5.  Maintain and enhance unit capabilities and readiness

Prior to deployment and regularly thereafter, ensure appropriate primary
prevention in the form of COSR briefs are offered to combatants,
providers, and the chain of command.

NOTE: For further discussion of the key element, please see Module A1:
Acute Stress Reaction.

A.  **Service Member With Symptoms Of Combat And Operational Stress
    Reaction (COSR) During Ongoing Military Operations**

> *Recommendations*

1.  Identify service member with symptoms compatible with COSR. Symptoms
    are not attributed to identified medical/surgical condition
    requiring other urgent treatment (a service member can have COSR
    concurrent with minor return-to-duty \[RTD\] wounds/illness)

2.  Evacuate to next level of care, if unmanageable

3.  Screen service member for symptoms of COSR, which include:

    -   Exhaustion/burnout

    -   Hyperarousal and anxiety

    -   Somatic complaints (gastrointestinal, genitourinary,
        musculoskeletal, cardiovascular, respiratory, nervous system)

    -   Depression or guilt/hopelessness

    -   Conversion Disorder symptoms

    -   Amnestic or dissociative symptoms

    -   Behavioral changes

    -   Emotional dysregulation

    -   Anger/irritability

    -   Brief, manageable \"psychotic symptoms\" (e.g., hallucination
        due to sleep deprivation and mild \"paranoia\")

4.  Address the underlying cause of symptoms (e.g., sleep deprivation)
    in brief restoration program. Advise service member´s Commander,
    chaplain, etc. on follow-up actions. Document symptoms and
    observations.

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B.  **Assess Risk Of Harm To Self Or Others; Seek Collateral Information
    About Stressors, And Service Member´s Function, Medical History, And
    Absence Or Impairment On Operation Or Mission**

> *Objective*
>
> Obtain information to assess service member´s condition and triage for
> appropriate care.
>
> *Recommendations*

1.  Arrange for a safe and comfortable environment to continue the
    evaluation. Secure any weapons and explosives.

2.  Medical triage to rule out:

    -   Neurotoxicant exposure

    -   Head injury

    -   Undetected wounds

    -   Acute physical illness (e.g., infectious)

3.  Document symptoms of COSR, obtain collateral information from unit
    leaders, and assess service member´s function, to include:

    -   Any changes in productivity?

    -   Coworker or supervisor reports of recent changes in appearance,
        quality of work, or relationships?

    -   Any tardiness/unreliability, loss of motivation, or loss of
        interest?

    -   Forgetful or easily distracted?

    -   Screening for substance use

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C.  **Can Service Member Return To Duty Within Hours?**

> *Objective*
>
> Identify service members who can rapidly resume effective functioning
> in the unit.
>
> *Recommendations*

1.  Consider the service member\'s role and functional capabilities and
    the complexity and importance of his/her job when determining when
    to return the service member to duty.

2.  The continuing presence of symptoms of COSR alone should not
    constitute a basis for preventing a return to duty.

3.  Educate and \"normalize\" observed psychological reactions to the
    chain of command.

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D.  **Initiate Acute Intervention For COSR; Coordinate With Service
    Member´s Unit/Command; Treat Within Closest Proximity To Service
    Member´s Unit, As Is Logistically Feasible**

> *Objective*
>
> Initiate acute symptom management.
>
> *Recommendations*

1.  Maintain sense of unit integrity:

    -   Normalization

    -   Validation

    -   Keep positive approach

    -   Set up expectation for recovery and RTD (role)

2.  Keep treatment consistent with the \"PIES\" principle:

    -   *Proximity*: Prevention and treatment are conducted in proximity
        to the battlefield or the origin of the stressor. Treatment
        proximate to the member´s unit where he/she can be visited by
        fellow military members is ideal. Consider all options for
        proximate treatment; strive to maintain connection to unit to
        maintain unit integrity

    -   *Immediacy*: Treatment should begin as soon as tactically and
        logistically possible

    -   *Expectancy*: From the outset, the expectation is that the SM is
        experiencing a normal reaction to an abhorrently abnormal
        situation and will return to duty following resolution,
        restitution and adaptation

    -   *Simplicity*: All modalities of prevention and treatment are
        simple and clearly understood. No dynamic therapy. No medical
        model. The only \"model\" is the military model---military
        members caring for military members.

3.  Initiate treatment:

    -   Treat according to SM´s prior role and not as a \"patient;\"
        avoid a hospital setting

    -   Assure or provide the following, as needed:

        -   Reunion or contact with primary group

        -   Respite from intense stress

        -   Thermal comfort

        -   Oral hydration

        -   Oral food

        -   Hygiene (toileting, shower, shave, and feminine)

        -   Sleep (to facilitate rest and restoration, use anxiolytic
            medication judiciously and sparingly in the acute setting)

        -   Encourage talk about the event with supportive others

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4.  Reserve group debriefing for members of preexisting and continuing
    groups at appropriate time and setting. Attendance should be
    voluntary and only be conducted by personnel trained in debriefing
    methods

5.  Assign job tasks and recreational activities that will restore focus
    and confidence and reinforce teamwork (limited duty)

6.  Avoid further traumatic events until recovered for full duty

7.  Evaluate periodically

8.  Consider using a short course of medication targeted for specific
    symptoms (see \"Pharmacotherapy for COSR\" in the original guideline
    document)

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E.  **Transfer To More Definitive Level of Care For Combat And
    Operational Stress Control**

> *Objective*
>
> Transfer service member for treatment augmentation or mental health
> treatment or referral.
>
> *Recommendations*

1.  Service members who do not respond to first line supportive
    interventions may warrant a transfer for treatment augmentation or
    mental health treatment or referral.

2.  Transfer to a more definitive level of treatment may include more
    intense or prolonged treatment at a Combat Refresher Training
    facility. Service members should be prepared for the transfer with
    continued positive expectation of recovery from their symptoms and
    return to normal level of functioning.

3.  Ensure that casualties being transferred due to other medical
    conditions (wounded in action) receive psycho-education relating to
    anticipated psychological changes, provide positive expectations,
    and offer support prior to departure from the area of
    responsibility.

MODULE B: ACUTE STRESS DISORDER (ASD) AND POST-TRAUMATIC STRESS DISORDER
(PTSD) IN PRIMARY CARE

A.  **Assessment of Trauma Exposure Related Symptoms**

> *Recommendations*
>
> [Assessment in Primary Care]{.underline}

1.  Patients who are presumed to have symptoms of PTSD or who are
    positive for PTSD on the initial screening should receive specific
    assessment of their symptoms. (For a list of \"Common Symptoms After
    Exposure to Trauma or Loss,\" see Table B-1 in the original
    guideline document.)

2.  A thorough assessment of the symptoms is necessary for accurate
    diagnosis, rating the severity of the disorder, and making correct
    clinical decisions. (Lagomasino, Daly, & Stoudemire , 1999; Williams
    & Shepherd, 2000); (**QE -- III, Overall Quality -- Poor, R -- I**)

3.  Consider self-administered checklists to ensure systematic,
    standardized, and efficient review of the patient´s symptoms.

4.  Useful information may include details such as time of onset,
    frequency, course, severity, level of distress, functional
    impairment, and other relevant information.

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B.  **Assessment of Trauma Exposure**

> *Recommendations*

1.  Assessment of the trauma exposure should include:

    -   History of exposure to traumatic event(s)

    -   Nature of the trauma

    -   Severity of the trauma

    -   Duration and frequency of the trauma

    -   Age at the time of the trauma

    -   Patient´s reaction at time of trauma (e.g., helplessness,
        horror, and fear)

    -   Existence of multiple traumas

2.  When assessing trauma exposure, the clinician must consider the
    patient´s ability to tolerate the recounting of traumatic material,
    since it may exacerbate PTSD symptoms.

3.  The assessment should be performed cautiously, especially in
    situations where the trauma source is still present and the patient
    perceives himself or herself to be in danger.

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C.  **Assessment Of Dangerousness To Self Or Others**

> *Recommendation*

1.  All patients with ASD/PTSD should be assessed for safety and
    dangerousness including current risk to self or others, as well as
    historical patterns of risk:

    -   Suicidal or homicidal ideation, intent (plan), means (e.g.,
        weapon, excess medications), history (e.g., violence or suicide
        attempts), behaviors (e.g., aggression, impulsivity),
        comorbidities (substance abuse, medical conditions) (Breslau at
        al., 2000; Bullman & Kang, 1994; Ferrada-Noli et al., 1998;
        Kaslow et al., 2000; Marshall et al., 2001; Prigerson & Slimack,
        1999; Swanson et al., 2002)(**QE -- II, II-2, III; Overall
        Quality -- Good; R -- B**)

    -   Family and social environment -- including risks to the family
        (Seng, 2002; Swanson et al., 2002)(**QE---III , II; Overall
        Quality -- Good; R -- B**)

    -   Ongoing health risks or risk-taking behavior (Acierno et al.,
        1996; Hutton et al., 2001) (**QE---II-2, II; Overall Quality --
        Good; R -- B**)

    -   Medical/psychiatric comorbidities or unstable medical conditions
        (Davidson et al., 1991; Farrell & Ganzini, 1995; Weisberg et
        al., 2002)(**QE -- II, III; Overall Quality -- Good; R -- B**)

    -   Consider potential to jeopardize mission in operational
        environment (Working Group Consensus)(**QE -- III, Overall
        Quality -- Poor, R -- I**)

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D.  **Obtain Medical History, Physical Examination, Mental Status
    Examination (MSE), and Laboratory Tests**

> *Objective*
>
> Obtain comprehensive patient data in order to reach a working
> diagnosis.
>
> *Recommendations*

1.  All patients should have a thorough medical and psychiatric history
    (Lagomasino, Daly, & Stoudemire, 1999; Williams & Shepherd,
    2000)(**QE -- III, Overall Quality -- Poor, R --** **I**), with
    particular attention paid to the following:

    -   Baseline functional/mental status

    -   Past medical history

    -   Medications, to include herbal and over-the-counter (OTC) drugs

    -   Past psychiatric history, to include prior treatment, past
        hospitalization for depression or suicidality, and substance use
        disorders

    -   Current life stressors

> If trauma exposure is recent (\<1 month) particular attention should
> be given to the following:

-   Exposure to/environment of trauma

-   Ongoing traumatic event

-   Exposure, perhaps ongoing, to environmental toxin

-   Ongoing perceived threat

2.  All patients should have a thorough physical examination. On
    physical examination, particular attention should be paid to the
    neurological exam and stigmata of physical/sexual abuse,
    self-mutilation, or medical illness. Note distress caused by or
    avoidance of diagnostic tests/examination procedures.

3.  All patients, particularly the elderly, should have a Mental Status
    Examination (MSE) to include assessment of the following:

    -   Appearance and behavior

    -   Language/speech

    -   Thought process (loose associations, ruminations, obsessions)
        and content (delusions, illusions, and hallucinations)

    -   Mood (subjective)

    -   Affect (to include intensity, range, and appropriateness to
        situation and ideation)

    -   Level of Consciousness (LOC)

    -   Cognitive function

4.  All patients should have routine laboratory screening tests
    including thyroid stimulating hormone (TSH), Complete Metabolic
    Panel, Hepatitis, human immunodeficiency virus (HIV), and human
    choriogonadotropin (HCG) (for females). Also consider CBC,
    urinalysis (UA), toxicology ethanol (Tox EtoH) panel and other
    tests, as clinically indicated. (Lagomasino, Daly & Stoudemire,
    1999; Williams & Shepherd, 2000)(**QE -- III, Overall Quality --
    Poor, R -- I**)

5.  Other assessments may be considered (radiology studies, EKG, and
    EEG), as clinically indicated. (Lagomasino, Daly & Stoudemire,
    1999)(**QE -- III, Overall Quality -- Poor, R -- I**)

6.  All patients should have a narrative summary of psychological
    assessments to include work/school, family, relationships, housing,
    legal, financial, unit/community involvement, and recreation, as
    clinically appropriate.

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E.  **Assessment Of Functioning**

> *Recommendation*

1.  Assessment of global function should be obtained, such as the Global
    Assessment of Function (GAF) scale or the SF-36. (Working Group
    Consensus) (**QE -- III, Overall Quality -- Poor, R -- I**)

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F.  **Assessment of Risk Factors**

> *Recommendations*

1.  All patients should be assessed for risk factors for developing ASD
    or PSTD. Special attention should be given to post-traumatic factors
    (i.e., social support and functional incapacity) that may be
    modified by intervention.

2.  Because of the high prevalence of psychiatric comorbidities in the
    PTSD population, assessment for depression and other psychiatric
    comorbidities is warranted (see also VA/DoD Clinical Practice
    Guideline for the Management of MDD and Psychotic Disorders).

3.  Substance use patterns of persons with trauma histories or PTSD
    should be routinely assessed to identify substance misuse or
    dependency (alcohol, nicotine, prescribed drugs, and illicit drugs)
    (see also VA/DoD Clinical Practice Guideline for the Management of
    Substance Use Disorders)

> *Evidence*
>
> [Pre-trauma]{.underline}

1.  Prior exposure to traumatic events (Breslau et al., \"Previous
    exposure\" 1999; Brewin, Andrews, & Valentine, 2000; Dougall et al.,
    2000; Green et al., 2000; Maes et al., 2001; Neria, Bromet, &
    Marshall, 2002; Ozer et al., 2003; Seedat & Stein, 2000; Zatzick et
    al., 2002)(**QE -- II, I; Overall Quality -- Good; R -- B**)

2.  Female gender (Breslau, \"Gender differences,\" 2002; Breslau et
    al., \"Vulnerability,\" 1999; Brewin, Andrews, & Valentine, 2000, I;
    Finnsdottir & Elklit, 2002; Neria, Bromet, & Marshall, 2002; Seedat
    & Stein, 2000; Stretch, Knudson, & Durand, 1998; Zatzick et al.,
    2002)(**QE -- II, I; Overall Quality -- Good; R -- B**)

3.  Psychiatric disorders or personality dimensions (Breslau,
    \"Epidemiologic studies,\" 2002; Brewin, Andrews, & Valentine, 2000;
    Maes et al., 2001; Norris et al., 2002; Ozer et al., 2003) (**QE --
    III, I, II; Overall Quality -- Good; R -- B**)

4.  Cognitive factors: Lower intelligence, Neurological soft signs
    (Brewin, Andrews, & Valentine, 2000; Gurvits et al., 2000) (**QE --
    I, II;** **Overall Quality -- Good; R -- B**)

5.  Parental or family history of PTSD (Yehuda et al., 1998) (**Quality
    of evidence -- II**; Overall Quality -- Poor; R -- I)

6.  Childhood abuse/assault (Breslau et al., \"Previous exposure,\"
    1999; Breslau, \"Epidemiologic studies,\" 2002; Brewin, Andrews, &
    Valentine, 2000; Neria, Bromet, & Marshall, 2002)(**QE -- II, III,
    I; Overall Quality -- Good; R -- B**)

7.  Low educational level or socioeconomic status (Armenian et al.,
    2000; Brewin, Andrews, & Valentine, 2000; Bromet et al., 2002;
    Finnsdottir & Elklit, 2002) (**QE -- II, I; Overall Quality -- Good;
    R -- B**)

> [Peri-trauma]{.underline}

8.  Severity of trauma; Perceived life threat (Armenian et al., 2000,
    II; Brewin, Andrews, & Valentine, 2000; Feehan et al., 2001; Ozer et
    al., 2003; Woods, 2000)(**QE -- II, I; Overall Quality -- Good; R --
    B**)

9.  Peri-traumatic dissociation (Ozer et al., 2003) (**QE -- I; Overall
    Quality -- Good; R -- B**)

10. Youth at time of exposure (Brewin, Andrews, & Valentine, 2000;
    Finnsdottir & Elklit, 2002; Neria, Bromet, & Marshall, 2002; Norris
    et al., 2002) (**QE -- I, II, III; Overall Quality -- Good; R --
    B**)

11. Biological factors such as heart rate (HR) increase (Shalev et al.,
    \"A prospective study,\" 1998; Yehuda, McFarlane, & Shalev, 1998)
    (**QE -- II; Overall Quality -- Fair; R -- C**)

> [Post-trauma]{.underline}

12. Resource loss/unemployment (Feehan et al., 2001; Norris et
    al., 2002) (**QE -- II, III; R -- B**)

13. Impaired social support system (Armenian et al., 2000; Brewin,
    Andrews, & Valentine, 2000; Gregurek et al., 2001; Ozer et al.,
    2003)(**QE -- II, I; Overall Quality -- Good; R -- B**)

14. Health problems (Norris et al., 2002) (**QE -- III, Overall Quality
    -- Poor, R -- I**)

15. On-going life stress (Brewin, Andrews, & Valentine, 2000; Norris et
    al., 2002) (**QE -- I, III; Overall Quality -- Good,**)

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G.  **Are There Clinical Significant Symptoms Suggestive of PTSD or
    ASD?**

> *Recommendations*

1.  Primary care providers should formulate a presumptive diagnosis of
    stress related disorder consistent with *Diagnostic and Statistical
    Manual of Mental Disorders (4^th^ edition)* criteria for ASD and
    PTSD.

2.  Primary care providers should consider initiating treatment or
    referral based on a working diagnosis of stress related disorder.

3.  Patients with difficult or complicated presentation of the
    psychiatric component should be referred to mental health specialty
    for diagnosis and treatment.

> *Evidence for all Recommendations*: (Working Group Consensus)(**QE --
> III; Overall Quality -- Poor; R -- C**)

H.  **Patient Education**

> *Objective*
>
> Help trauma survivors cope with ASD/PTSD by providing information that
> may help them manage their symptoms and benefit from treatment.
>
> *Recommendation*

1.  Trauma survivors should be educated about PTSD symptoms, other
    potential consequences of exposure to traumatic stress, practical
    ways of coping with traumatic stress symptoms, processes of recovery
    from ASD/PTSD, and the nature of treatment. (Working Group
    Consensus) (**QE -- III; Overall Quality -- Poor; R -- I**)

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I.  **Coexisting Severe Medical Conditions**

> *Objective*
>
> Improve management of PTSD symptoms when they are complicated by the
> presence of a medical or psychiatric comorbidity.
>
> *Recommendations*

1.  Primary care providers should recognize that medical
    disorders/symptoms, mental disorders, and psychosocial problems
    commonly coexist with PTSD and should screen for them during the
    evaluation and treatment of PTSD. (Working Group Consensus) **(QE --
    III; Overall Quality -- Poor; R -- I**)

2.  Consider the existence of comorbid conditions when deciding whether
    to treat patients in the primary care setting or refer them for
    specialty mental health care. (Working Group Consensus) (**QE --
    III; Overall Quality -- Poor; R -- I**)

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J.  **Concurrent PTSD and Substance Abuse**

> *Objective*
>
> Improve the management of PTSD symptoms when they are complicated by a
> concurrent substance abuse problem.
>
> *Recommendations*

1.  Substance use patterns of clients with trauma histories or PTSD
    should be routinely assessed (see the VA/DoD Clinical Practice
    Guideline for the Management of Substance Use Disorders) (Working
    Group Consensus) (**QE -- III; Overall Quality -- Poor; R -- I**)

2.  Substance abusers should be routinely screened for trauma exposure
    and PTSD. (Dansky et al., 1997) (**QE -- III; Overall Quality --
    Poor; R -- I**)

3.  Integrated PTSD-Substance Abuse Treatment should be considered.
    (Working Group Consensus) (**QE -- III; Overall Quality -- Poor; R
    -- I**)

4.  Substance-abusing patients with PTSD should be educated about the
    relationships between PTSD and substance abuse, referred for
    concurrent PTSD treatment, or provided with integrated
    PTSD/Substance Abuse treatment. (Working Group Consensus; Najavits,
    2002; Ouimette et al., 1998) (**QE -- III; Overall Quality -- Poor;
    R -- I**)

5.  Substance Abuse-PTSD patients should receive follow-up care that
    includes a continued focus on PTSD issues. (Ouimette et al., 2000)
    (**QE -- II-3, Overall Quality -- Fair, R -- I**)

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K.  **Referral to Mental Health Specialty**

> *Objective*
>
> Provide guidance for primary care providers on optimal referral for
> PTSD patients.
>
> *Recommendations*

1.  Primary care providers should consult with a mental health provider
    and/or a PTSD Specialty Team for all patients with acute or chronic
    stress disorders.

2.  Primary care providers should continue to be involved in the
    treatment of patients with acute or chronic stress disorders.

3.  Treatment for patients with ASD or acute or chronic PTSD should
    involve a multidisciplinary team approach to include occupational
    therapy (OT), spiritual counseling, recreation therapy, social work,
    psychology, and/or psychiatry.

4.  Patients with clinically significant symptoms or comorbidities to
    PTSD, including chronic pain, insomnia, anxiety, and depression,
    should receive treatment for those complicating problems.

5.  Case management should be provided, as indicated, to address high
    utilization of medical resources.

6.  Consider referral for alternative care modalities as indicated for
    patient symptoms, consistent with available resources, and resonant
    with patient belief systems.

> *Evidence for all recommendations*: (Working Group Consensus)(**QE --
> III; Overall Quality -- Poor; R -- I**).

L.  **Treatment in Primary Care**

> *Recommendations*
>
> [ALL PATIENTS with Stress Related Disorders]{.underline}

1.  A supportive and collaborative treatment relationship or therapeutic
    alliance should be developed and maintained with patients with
    ASD/PTSD inclusive of their input in treatment planning.

2.  Primary care providers should routinely provide the following
    services for all patients with stress related disorders, especially
    those who are reluctant to seek specialty mental health care:

    -   Supportive counseling

    -   PTSD-related education

    -   Regular follow-up and monitoring of symptoms

    -   Early recognition of PTSD

3.  Primary care providers should consider consultation with mental
    health providers for patients with ASD/PTSD who warrant a mental
    health referral but may be reluctant or refuse it.

4.  Primary care providers should take leadership in convening a
    collaborative team for patients with PTSD. Team members may include
    the primary care providers, mental health specialists, chaplains,
    pastors, social worker, occupational or recreational therapists, Vet
    Centers, family support centers, exceptional family member programs,
    VA benefit counselors, peer-support groups, and others.

> [ASD]{.underline}

5.  Because ASD does not occur in all people who later develop PTSD,
    consider treatment for acutely traumatized people with ASD, with
    severe PTSD symptoms as well as for those who are incapacitated by
    acute psychological or physical symptoms.

6.  Patients with ASD should be monitored for development of PTSD
    (Brewin et al., 1999; Bryant et al., 1998) (**QE -- I, Overall
    Quality -- Good, R -- A**). The use of validated PTSD symptom
    measure such as the PTSD Checklist should be considered (see
    Appendix D in the original guideline document).

7.  Primary care providers should consider the pharmacological
    management of disruptive symptoms (e.g., sleep) (see
    \"Pharmacotherapy for ASD\" in the original guideline document).

8.  Brief intervention (4 to 5 sessions) of cognitive behavioral therapy
    (CBT) is an effective early intervention for patients with ASD
    (Bryant et al., 1998; Foa et al., 1995)(**QE -- I, Overall Quality
    --Good, R -- A**). In addition to targeted brief interventions, some
    trauma survivors may benefit from follow-up provision of ongoing
    counseling or treatment.

> [PTSD]{.underline}

9.  All patients with PTSD should have a specific primary care provider
    assigned to coordinate their overall health care.

10. Pharmacological management of PTSD or related symptoms may be
    initiated based on a presumptive diagnosis of PTSD. Long-term
    pharmacotherapy will be coordinated with other intervention once the
    patient has been referred to a mental health clinic (see
    \"Pharmacotherapy for PTSD\" in the original guideline document).

11. Primary care providers should perform a brief PTSD symptom
    assessment at each visit. The use of a validated PTSD symptom
    measure, such as PTSD Checklist, should be considered (see Appendix
    D in the original guideline document).

12. Primary care providers should assess patients with PTSD for
    associated high-risk behaviors (e.g., smoking, alcohol/drug abuse,
    HIV, and hepatitis risks) and comorbid medical and psychiatric
    illnesses.

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M.  **Referral to Vet Centers**

> *Objective*
>
> Provide timely mental health services to veterans in need of support.
>
> *Recommendations*

1.  Veterans with symptoms of PTSD should have an initial assessment of
    needs.

2.  Veterans who are dangerous to self or others should be referred to
    the local Veterans Affairs Medical Center (VAMC) or nearest
    emergency room.

3.  Veterans who are seeking to have basic needs met should be referred
    to the VA Homeless Coordinator or community resources for food,
    shelter, or emergency financial assistance.

4.  Veterans who are eligible for Vet Center services should have an
    in-depth psychological history taken, including a comprehensive
    military history and treatment plan.

5.  Treatment plans in the Vet Center may include individual, family, or
    group therapy. Veterans can receive medical treatment or medication
    management at the Vet Center by a psychiatrist, registered nurse
    (RN), or advanced registered nurse practitioner (ARNP) or be
    referred to the local VAMC, Community Based Outpatient Clinic
    (CBOC), or community resources.

6.  Veterans who are eligible for Vet Center services should be made
    aware of the Center resources and referred if the patient desires.

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N.  **Assess Duty/Work Responsibilities and Patient´s Fitness (In
    Relation to Military Operation)**

> *Recommendations*

1.  The determination of when to return a service member to duty should
    take into consideration the individual´s service member´s role, the
    complexity and importance of his or her job, and the service
    member´s functional capabilities.

2.  The continuing presence of symptoms of PTSD should not be considered
    as the sole basis for preventing a return to duty.

MODULE C

MANAGEMENT OF PTSD IN MENTAL HEALTH SPECIALITY CARE

A.  **Patient Presenting To Mental Health With Suspected PTSD Symptoms**

> *Recommendations*
>
> [Assessment in Mental Health Specialty]{.underline}

1.  Mental health clinicians should obtain a comprehensive diagnostic
    assessment that includes, but is not limited to, the symptoms that
    characterize PTSD.

2.  Routine use of self-administered checklists may ensure systematic,
    standardized, and efficient review of the patient´s symptoms and
    history of trauma exposure (see Appendix C \[PCL-C\] in the original
    guideline document).

3.  The assessment should also include review of other salient symptoms
    (guilt, dissociation, derealization, depersonalization, reduction,
    and awareness of surrounding) that impact on treatment decisions.
    Structured psychiatric interviews, such as the clinician
    administered PTSD scale (CAPS), may be considered.

> *For discussion see CORE Module Annotation D, and Module B --
> Management of ASD and PTSD in Primary Care Annotations A and B*

B.  **Obtain Medical History, Physical Examination, MSE, Psychosocial
    Assessment, and Appropriate Lab Tests**

> *See Module B: Management of ASD & PTSD in Primary Care, Annotation D,
> E and F.*

C.  **Does Patient Meet DSM-IV Criteria For ASD/PTSD?**

> *Objective*
>
> Diagnose ASD/PTSD by DSM-IV criteria.
>
> *Recommendation*

1.  Diagnostic criteria should be documented in the medical record.

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D.  **Educate Patients and Family About Treatment Options; Develop
    Collaborative and Interdisciplinary Treatment Plan**

> *See Module B: Management of ASD & PTSD in Primary Care, Annotation
> H.*

E.  **Initiate Therapy for PTSD**

> *See Intervention Module*

F.  **PTSD with other Comorbid Symptoms (Addiction, Substance Use
    Disorder \[SUD\], Psychosis, Bipolar)**

> *See Module B: Management of ASD & PTSD in Primary Care, Annotation I
> & J*

G.  **Reassess PTSD Symptoms; Diagnostic Status, Functional Status;
    Quality of Life; Additional Treatment Needs; Patient Preferences**

> *Objective*
>
> Assess patient status following therapeutic intervention to determine
> future direction.
>
> *Recommendations*

1.  Follow-up status of patients with PTSD should be monitored at least
    every three months. Use interview and questionnaire methods to
    assess PTSD symptoms and function.

    -   Diagnostic status and symptom severity

    -   Functional status/health-related quality of life

    -   Psychosocial treatment needs

    -   Patient preferences

    -   Therapy adherence

    -   Adverse treatment effects

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H.  **Follow-up in Mental Health**

> *Recommendations*

1.  If patient does not improve or status worsens, consider one of the
    following treatment modification options:

    -   Continued applications of the same modality at intensified dose
        and/or frequency

    -   Change to a different treatment modality

    -   Apply adjunctive therapies

    -   Increase level of care (e.g., referral facility, partial
        hospitalization, inpatient hospitalization, residential care)

    -   Consider a referral to adjunctive services for treatment for
        comorbid disorders or behavioral abnormalities (e.g.,
        homelessness, domestic violence, or aggressive behavior)

2.  If patient demonstrates partial (insufficient) remission, consider
    one of the following treatment modification options:

    -   Continue the present treatment modality to allow sufficient time
        for a full response

    -   Continue applications of the same modality at intensified dose
        and/or frequency

    -   Change to a different treatment modality

    -   Apply adjunctive therapies

    -   Increase level of care (e.g., referral facility, partial
        hospitalization, inpatient hospitalization, residential care)

    -   Consider a referral to adjunctive services for treatment of
        comorbid disorders or behavioral abnormalities (e.g.,
        homelessness or domestic violence)

3.  If patient demonstrates improved symptoms and functioning but
    requires maintenance treatment:

    -   Continue current course of treatment

    -   Consider stepping down the type, frequency, or dose of therapy

        -   Transition from intensive psychotherapy to case management
            contacts

        -   Transition from individual to group treatment modalities

    -   Discuss patient status and need for monitoring with the primary
        care provider

    -   Consider a referral to adjunctive services for treatment of
        disorders or behavioral abnormalities (e.g., homelessness or
        domestic violence)

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4.  If patient demonstrates remission from symptoms and there are no
    indications for further therapy:

    -   Discontinue treatment

    -   Educate the patient about indication and route of future care
        access

    -   Monitor by primary care for relapse/exacerbation.

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I.  **Referral**

> *Objective*
>
> Treat symptoms, support function, and alleviate suffering in those
> patients with PSTD who are unwilling, unable, or unsuitable for
> treatment in a mental health setting.
>
> *Recommendations*

1.  Evaluate psychosocial function and refer for psychosocial services,
    as indicated. Available resources include, but are not limited to
    chaplains, pastors, Family Support Centers, Exceptional Family
    Member Programs, VA benefit counselors, occupational or recreational
    therapists, Vet Centers, and peer-support groups.

2.  Provide case management, as indicated, to address high utilization
    of medical resources.

3.  Consider psychotherapeutic interventions as appropriate for level of
    training and available resources.

4.  For patients with severe symptoms or coexisting psychiatric problems
    consider referrals to:

    -   Specialized PTSD programs

    -   Specialized programs for coexisting problems and conditions

    -   Partial psychiatric hospitalization or \"day treatment\"
        programs

    -   Inpatient psychiatric hospitalization

> *Evidence for all Recommendations*: (Working Group Consensus)(**QE --
> III; Overall Quality -- Poor; R -- I**)

EVIDENCE-BASED INTERVENTION FOR TREATMENT OF PTSD

A.  **Acute Stress Disorder (ASD) Pharmacotherapy**

> **Summary Table -- Pharmacotherapy for ASD**

  -----------------------------------------------------------------------------
  **R\***   **Significant   **Some        **Unknown**        **No
            Benefit**       Benefit**                        Benefit/Harm**
  --------- --------------- ------------- ------------------ ------------------
  **A**                                                       

  **B**                     Imipramine                        

  **C**                     Propranolol                       

  **I**                                   Benzodiazepines\    
                                          Other              
                                          Sympatholytics\    
                                          Other              
                                          Antidepressants\   
                                          Anticonvulsants\   
                                          Atypical           
                                          Antipsychotics\    
                                          Chloral Hydrate    

  **D**                                                      Typical
                                                             Antipsychotics
  -----------------------------------------------------------------------------

> \*R = level of recommendation
>
> Although the effectiveness of selective serotonin reuptake inhibitors
> (SSRIs) has been demonstrated for PTSD, it has not been tested in ASD
> and therefore cannot be recommended.
>
> *Objective*
>
> To lessen the physical, psychological, and behavioral morbidity
> associated with acute stress reaction, hasten the return to full
> function (duty, work, social function), and diminish the likelihood of
> chronicity.
>
> *Recommendations*

1.  Recommend providing for physical needs, sleep, normalization, and
    other non-pharmacological modalities (Working Group Consensus)(**QE
    -- III; Overall Quality -- Poor; R \-- not graded**)

2.  Consider the use of medication for individuals that do not respond
    to non-pharmacological treatment (Working Group Consensus) (**QE --
    III; Overall Quality -- Poor; R -- I**)

3.  Consider the use of imipramine to ameliorate the symptoms of ASD

4.  Consider a short course of medication targeted for specific symptoms

    -   Sleep disturbance/insomnia

        -   Benzodiazepines (up to 5 days) (Gelpin et al., 1996;
            Mellman, Byers, & Augenstein, 1998) (**QE -- II-2; Overall
            Quality -- Fair; Net Effect -- M; R -- C**)

        -   Chloral hydrate (up to 5 days) (Robert et al., 1999) (**QE
            -- I**; **Overall Quality -- Fair; Net Effect -- S; R --
            C**)

    -   Hyperarousal/excessive arousal/panic attacks

        -   Propranolol and other anti-adrenergic agents (up to 10 days)
            (Pittman et al., 2002) (**QE -- I; Overall Quality -- Good;
            Net Effect -- M; R -- C**)

        -   Imipramine (up to 7 days) (Robert et al., 1999) (**QE -- I;
            Overall Quality -- Fair; Net Effect -- M; R -- B**)

        -   Benzodiazepines (up to 5 days) avoid short acting agent
            (e.g., alprazolam) (Gelpin et al., 1996; Mellman, Byers, &
            Augenstein, 1998) (**QE -- II-2; Overall Quality -- Fair;
            Net Effect -- M; R -- C**)

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5.  There is insufficient evidence to support a recommendation for
    preventative use of a pharmacological agent to prevent the
    development of PTSD.

6.  There is insufficient evidence to support a recommendation for PTSD
    pharmacotherapies for patient presenting symptoms for less than 4
    weeks. (**QE -- I; Overall Quality -- Poor; R \-- I**)

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B.  **Post-Traumatic Stress Disorder (PSTD) Pharmacotherapy**

> **Summary Table for PTSD Pharmacotherapy\***

  ----------------------------------------------------------------------------------
  **R\***   **Significant   **Some Benefit**  **Unknown**         **No
            Benefit**                                             Benefit/Harm**
  --------- --------------- ----------------- ------------------- ------------------
  **A**     SSRIs                                                  

  **B**                     TCAs\                                  
                            MAOIs                                 

  **C**                     Sympatholytics\                        
                            Novel                                 
                            Antidepressants                       

  **I**                                       Anticonvulsants\     
                                              Atypical            
                                              Antipsychotics\     
                                              Buspirone\          
                                              Nonbenzodiazepine   
                                              hypnotics           

  **D**                                                           Benzodiazepines\
                                                                  Typical
                                                                  Antipsychotics
  ----------------------------------------------------------------------------------

> \*R = level of recommendation; SSRIs = selective serotonin reuptake
> inhibitors; TCAs = tricyclic antidepressants; MAOIs = monoamine
> oxidase inhibitors.
>
> *Objective*
>
> To minimize signs and symptoms of PTSD and maintain function.
>
> *Recommendations*
>
> [Monotherapy]{.underline}

1.  Strongly recommend selective serotonin reuptake inhibitors (SSRIs)
    for the treatment of PTSD. (Stein et al., 2000) (**QE -- I; Overall
    Quality -- Good; Net Effect -- M; R -- A**)

2.  Recommend tricyclic antidepressants (TCAs) and monoamine oxidase
    inhibitors (MAOIs) as second-line treatments for PTSD. (Stein et
    al., 2000; Cochrane Review) (**QE -- I; Overall Quality -- Good; Net
    Effect -- M; R -- B**)

3.  Consider an antidepressant therapeutic trial of at least 12 weeks
    before changing therapeutic regimen. (Martenyi et al., 2002) (**QE
    -- I; Overall Quality -- Fair; Net Effect -- M; R -- B**)

4.  Consider a second-generation (e.g., nefazodone, trazodone,
    venlafaxine, mirtazapine, bupropion) in the management of PTSD.
    (Hidalgo et al., 1999) (**QE -- II-2; Overall Quality -- Fair; Net
    Effect -- S; R -- C**)

> [Augmented Therapy for Targeted Conditions]{.underline}

5.  Consider prazosin to augment the management of nightmares and other
    symptoms of PTSD. (Raskind et al., 2003) (**QE -- I; Overall Quality
    -- Fair; Net Effect -- M; R -- C**)

6.  Recommend medication compliance assessment at each visit. (Group
    Consensus) (**QE -- III; Overall Quality -- Poor; R -- I**)

7.  Since PTSD is a chronic disorder, responders to pharmacotherapy may
    need to continue medication indefinitely; however, it is recommended
    that maintenance treatment should be periodically reassessed.
    (Rapaport, Endicott, & Clary, 2002) (**QE -- II; Overall Quality --
    Fair; Net Effect -- S; R -- C**)

8.  There is insufficient evidence to recommend a mood stabilizer (e.g.,
    lamotrigine) for the treatment of PTSD. (Hertzberg et al., 1999)
    (**QE -- I; Overall Quality -- Fair; Net Effect -- M; R -- C**)

9.  There is insufficient evidence to recommend atypical antipsychotics
    for the treatment of PTSD. (Hamner et al., 2003) (**QE -- I; Overall
    Quality -- Good; Net Effect -- S; R -- I**)

10. There is insufficient evidence to support the recommendation for a
    pharmacological agent to prevent the development of PTSD. (**QE --
    III; Overall Quality -- Poor; Net Effect -- S; R -- I**)

11. Recommend against the long-term use of benzodiazepines to manage
    core symptoms in PTSD. (Kosten et al., 2000) (**QE -- II-2; Overall
    Quality -- Fair; Net Effect -- M; R -- I**)

12. Recommend against typical antipsychotics in the management of PTSD.
    (Stein et al., 2000) (**QE -- I; Overall Quality -- Poor; Net Effect
    -- S; R -- D**)

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C.  **Psychotherapy Interventions**

> *Objective*
>
> Reduce symptoms severity and improve of global functioning.
>
> **Summary Table for Psychotherapy Interventions**

  ------------------------------------------------------------------------------
  **R\***   **Significant     **Some          **Unknown**      **Harm**
            Benefit**         Benefit**                        
  --------- ----------------- --------------- ---------------- -----------------
  **A**     Cognitive Therapy                                   
            (CT)\                                              
            Exposure Therapy                                   
            (ET)\                                              
            Stress                                             
            Inoculation                                        
            Training (SIT)\                                    
            Eye Movement                                       
            Desensitization                                    
            and Reprocessing                                   
            (EMDR)                                             

  **B**                       Imagery                           
                              Rehearsal                        
                              Therapy (IRT)\                   
                              Psychodynamic                    
                              Therapy                          

  **C**                                                         

  **D**                                                         

  **I**                       PTSD- Patient                     
                              Education                        
  ------------------------------------------------------------------------------

> \*R = level of recommendation
>
> *Recommendations*

1.  Providers should explain to all patients with PTSD the range of
    available and effective therapeutic options for PTSD. (Expert
    Consensus)

2.  Cognitive Therapy (CT), Exposure Therapy (ET), Stress Inoculation
    Training (SIT), and Eye Movement Desensitization and Reprocessing
    (EMDR) are strongly recommended for treatment of PTSD in military
    and non-military populations. EMDR has been found to be as effective
    as other treatments in some studies and less effective than other
    treatments in some other studies. (**A**\*)

3.  Imagery Rehearsal Therapy \[IRT\] and Psychodynamic Therapy may be
    considered for treatment of PTSD. (**B\***)

4.  Patient education is recommended as an element of treatment of PTSD
    for all patients. (**C\***)

5.  Consider Dialectical Behavioral Therapy (DBT) for patients with a
    borderline personality disorder typified by parasuicidal behaviors.
    (**B**)

6.  Consider hypnotic techniques especially for symptoms associated with
    PTSD, such as pain, anxiety, dissociation and nightmares, for which
    hypnosis has been successfully used. (**B\***)

7.  Specialized PTSD psychotherapies may be augmented by additional
    problem specific methods/services and pharmacotherapy. (Expert
    Consensus)

8.  Combination of cognitive therapy approaches (e.g., ET plus CT),
    while effective, has not proven to be superior to either component
    alone. (**B**)

9.  Specific psychotherapy techniques may not be uniformly effective
    across all patients. When selecting a specific treatment modality,
    consideration of patient characteristics such as gender, type of
    trauma (e.g., combat vs. other trauma), and past history may be
    warranted. (Expert Consensus)

10. Patient and provider preferences should drive the selection of
    evidence-based psychotherapy and/or evidence-based pharmacotherapy
    as the first line treatment. (Expert Consensus)

11. Selection of individual interventions should be based upon patient
    preference, provider level of skill and comfort with a given
    modality, efforts to maximize benefit and minimize risks to the
    patient, and consideration of feasibility and available resources.
    (Expert Consensus)

12. Psychotherapies should be provided by practitioners who have been
    trained in the particular method of treatment, whenever possible.
    (Expert Consensus)

13. A stepped care approach to therapy administration may be considered,
    though supportive evidence is lacking. (Expert Consensus)

> \*Detailed evidence tables for each therapy are included in the
> applicable following Discussion sections.
>
> *Note: Psychotherapy interventions are aimed at reduction of symptoms
> severity and improvement of global functioning. However, the clinical
> relevance and importance of other outcome indicators (e.g.,
> improvement of quality of life, physical and mental health) are not
> currently well known*.

A.  **Selection of Therapy for PTSD**

> In clinical practice, providers and patients alike are often faced
> with important decisions relating to type, number, frequency, and dose
> of various psychotherapies and pharmacologic therapies. Therapies may
> be broadly divided into (1) evidence-based psychotherapies, (2)
> evidence-based pharmacotherapies, and (3) key adjunctive or
> supplemental treatment modalities. Providers should explain to all
> patients with PTSD the range of therapeutic options that are available
> and effective for PTSD. This discussion should include general
> advantages and disadvantages (including side-effects) associated with
> each therapeutic option. In general, PTSD therapy research has
> provided insufficient evidence to favor medication or evidence-based
> psychotherapy as a first-line treatment. There is also insufficient
> evidence to suggest for or against combined medication and
> psychotherapy over only one of the two approaches.
>
> It may be helpful to add therapies using a stepped care approach, even
> though supporting evidence does not exist. The use of stepped care has
> been advocated for many chronic conditions including hypertension, low
> back pain, and depression. In stepped care, the intensity of care is
> augmented for patients who do not achieve an acceptable outcome with
> lower levels of care. Stepped care is based on three assumptions:
> different people require different levels of care; finding the right
> level of care often depends on monitoring outcomes; and moving from
> lower to higher levels of care based on patient outcomes often offers
> efficient increases in overall effectiveness.
>
> The level or intensity of care is guided by illness trajectory (degree
> of chronicity and current illness severity), observed outcomes, and
> previously attempted therapies. Active follow-up is used to determine
> the level of care each patient requires over time. In PTSD for
> example, the patient and provider may determine that the first-line
> therapy will be psychotherapy. If, after a period of treatment, the
> patient is not responding adequately, the patient may be \"stepped
> up\" in therapeutic intensity by adding a medication, such as a
> selective serotonin reuptake inhibitor (SSRI) to the regimen of
> ongoing psychotherapy. Contrary to clinical intuition, there is no
> evidence indicating the superiority of programs that combine different
> cognitive behavioral therapies.

B.  **Cognitive Therapy (CT)**

> *Recommendations*

1.  CT is effective with civilian men and women exposed to combat and
    noncombat trauma. (Lovell, et al., 2001; Marks et al., 1998) (**QE
    -- I; Overall Quality -- Good; R -- A**)

2.  CT is effective with military and veterans with combat- and
    noncombat-related PTSD. (Working Group Consensus) (**QE -- III;
    Overall Quality -- Poor; R -- I**)

3.  CT is effective for women with PTSD associated with sexual assault.
    (Resick et al., 2002)(**QE -- I, Overall Quality -- Good, R -- A**)

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C.  **Exposure Therapy**

> *Recommendations*

1.  ET is effective in the treatment of PTSD (compared to placebo or
    waiting list) (Cooper & Clum, 1989; Foa et al., 1991; Foa et al.,
    \"A comparison,\" 1999; Ironson et al., 2002; Keane et al., 1989;
    Marks et al., 1998; Tarrier et al., 1999) (**QE -- I; Overall
    Quality -- Good; R -- A**)

2.  ET compared to other forms of therapy show equivalent results (Foa
    et al., 1991; Foa et al., \"A comparison,\"1999; Marks et al., 1998;
    Paunovic & Ost, 2001; Resnick & Nishisth, 2001; Schnurr, 2001;
    Tarrier et al., 1999) (**QE -- I; Overall Quality -- Good; R -- A**)

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D.  **Stress Inoculation Training (SIT)**

> *Recommendations*

1.  SIT is effective as a treatment for PTSD related to sexual assault
    (Foa et al., 1991; Foa et al., \"A comparison,\" 1999; Kilpatrick,
    Veronen, & Resick, 1982; Rothbaum et al., 2000) (**QE -- I; Overall
    Quality -- Good; R -- A**)

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E.  **Eye Movement Desensitization and Reprocessing (EMDR)**

> *Recommendations*

1.  EMDR is more efficacious for PTSD than wait-list, routine care, and
    active treatment controls. (Chemtob, Tolin, & van der Kolk, 2000;
    Davidson & Parker, 2001; Foa & Meadows, 1997; Maxfield & Hyer, 2002;
    Shepherd, Stein, & Milne, 2000) (**QE -- I; Overall Quality -- Good;
    R -- A**)

2.  Eye movements are not critical to the effects of EMDR (Foa &
    Meadows, 1997) (**QE -- I; Overall Quality -- Poor; R -- C**)

3.  EMDR compared with ET and CT shows mixed results (Cahill, 2000;
    Davidson & Parker, 2001; Foa & Meadows, 1997; Ironson et al., 2002;
    Lee et al., 2002; Power et al., 2002; Servan-Schrieber, 2000;
    Shepherd, Stein, & Milne, 2000; Taylor, Thordarson, & Maxfield,
    2002; Van Etten & Taylor, 1998) (**QE -- I, Overall Quality -- Fair,
    R -- B**)

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F.  **Imagery Rehearsal Therapy (IRT)**

> *Recommendations*

1.  IRT can be considered for treatment of PTSD (nightmare and sleep
    disruption in particular). (Krakow et al., 1995; Krakow et al.,
    \"Imagery rehearsal,\" 2001; Krakow et al., \"Treatment of chronic
    nightmares,\" 2001; Forbes, Phelps, & McHugh, 2001) (**QE -- I;
    Overall Quality -- Fair; R -- B**)

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G.  **Psychodynamic Therapy**

> *Recommendations*

1.  Psychodynamic psychotherapy for the treatment of PTSD (Brom, Kleber,
    & Defares, 1989**) (QE -- I; Overall Quality -- Good; R -- B**)

2.  Psychodynamic psychotherapy for patients with complex PTSD
    (Courtois, 1999; Roth & Batson, 1997; Shengold, 1989) (**QE -- II-2;
    Overall Quality -- Fair; R -- B**)

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H.  **Patient Education**

> *Objective*
>
> Provide a therapeutic intervention that reduces the symptoms and
> functional impairments of PTSD.
>
> *Recommendation*

1.  Psychoeducation is recommended (Foa, Davidson, & Frances, 1999)
    (**QE -- III; Overall Quality -- Poor; R -- C**) (Lubin et
    al., 1998) (**QE -- II-2; Overall Quality -- Fair; R -- B**)

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I.  **Group Therapy**

> *Objective*
>
> Provide a supportive environment in which a patient with PTSD may
> participate in therapy with other PTSD patients.
>
> *Recommendations*

1.  Consider group treatment for patients with PTSD (Donovan,
    Padin-Rivera, & Kowaliw, 2001; Foy et al., 2000; Rogers et
    al., 1999) (**QE -- III, II, I; Overall Quality -- Fair; R -- B**)

2.  Current findings do not favor any particular type of group therapy
    over other types. (Foy et al., 2000) (**QE -- II, Overall Quality --
    Poor, R -- I**)

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J.  **Dialectical Behavior Therapy**

    1.  Consider DBT for patients with a borderline personality disorder
        typified by parasuicidal behaviors. (Evans et al., 1999; Hawton
        et al., 2000; Linehan, Heard, & Armstrong, 1993; Safer, Telch, &
        Agras, 2001; Telch, Agras, & Linehan, 2001; van den Bosch et
        al., 2002; Verheul et al., 2003) (**QE -- I; Overall Quality --
        Fair; R -- B**)

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K.  **Hypnosis**

> *Objective*
>
> A therapeutic intervention that may be an effective adjunctive
> procedure in the treatment of PTSD
>
> *Recommendation*

1.  Hypnosis may be used to alleviate PTSD symptoms. (Brom, Kleber, &
    Defares, 1989; Sherman, 1998) (**QE -- I; Overall Quality --Fair; R
    -- B**)

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L.  **Psychosocial Adjunctive Methods/Services**

> *Objective*
>
> Provide a therapeutic intervention that facilitates generalizing
> skills for coping with PTSD from clinic to home/work/community.
>
> *Recommendations*

1.  Consider psychosocial rehabilitation techniques once the client and
    clinician identify the following kind of problems associated with
    the diagnosis of PTSD: persistent high-risk behaviors, lack of self
    care/independent living skills, homelessness, interactions with a
    family that does not understand PTSD, socially inactive, unemployed,
    and encounters with barriers to various forms of
    treatment/rehabilitation services.

2.  Client and clinician should determine whether such problems are
    associated with core symptoms of PTSD and, if so, then ensure that
    rehabilitation techniques are used as a contextual vehicle for
    alleviating PTSD symptoms.

3.  Psychosocial rehabilitation should occur concurrently or shortly
    after a course of treatment for PTSD, since psychosocial
    rehabilitation is not trauma-focus.

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M.  **Spiritual Support**

> *Objective*
>
> Reduce symptoms of PTSD and improve patient´s functioning through
> social and spiritual support.
>
> *Recommendation*

1.  Provide access to religious/spiritual resources, if sought.

> *Evidence*
>
> Provide opportunities to vent & defuse, to share feelings and talk
> (Bogia & Preston, 1985; Everly, \"The role of pastoral crisis,\" 2000;
> Hunter, 1996) (**QE -- II, Overall Quality -- Fair, R -- C**)

**Abbreviation/Acronym List**

**ABCs** Airway, breathing, circulation\
**AHCPR** Agency for Healthcare Policy and Research\
**APA** American Psychiatric Association\
**ASD** Acute stress disorder\
**ASR** Acute stress reaction\
**AUDIT** Alcohol Use Disorders Identification Test\
**CAGE** Alcohol abuse/dependence screening test mnemonic\
**CAPS** Clinician Administered PTSD Scale\
**CBC** Complete blood count\
**CBT** Cognitive Behavioral Therapy\
**CCTR** Cochrane Central Register of Controlled Trials\
**CDR** Commander\
**CNS** Central nervous system\
**COSR** Combat and operational stress reactions\
**CISD** Critical Incident Stress Debriefing\
**CT (Interventions)** Cognitive Therapy\
**CT** Computed tomography\
**CV** Cardiovascular\
**DARE** Database of Abstracts of Reviews of Effectiveness\
**DAST** Drug Abuse/Dependence Screener\
**DBT** Dialectical Behavioral Therapy\
**DoD** Department of Defense\
**DSM-IV** Diagnostic and Statistical Manual of Mental Disorders (4th
edition)\
**DTE** Direct Therapeutic Exposure\
**EBM** Evidence-based medicine\
**EBPTU** Evaluation and Brief PTSD Treatment Unit\
**EEG** Electroencephalography\
**EKG** Electrocardiogram\
**EMDR** Eye Movement Desensitization and Reprocessing\
**EMTs** Emergency Medical Teams\
**ESRT** Emotional Self-Regulation Therapy\
**EtoH** Ethanol\
**ET** Exposure Therapy\
**FDA** U. S. Food and Drug Administration\
**GAF** Global Assessment of Function\
**GI** Gastrointestinal\
**GU** Genitourinary\
**HCG** Human Choriogonadotropin\
**HIV** Human immunodeficiency virus\
**IRT** Image Rehearsal Therapy\
**LOC** Level of consciousness\
**LOF** Level of function\
**MAOIs** Monoamine oxidase inhibitors\
**MAST** Michigan Alcohol Screening Test\
**MDD** Major Depressive Disorder\
**MHP** Mental health providers\
**MI** Myocardial infarction\
**MMSE** Mini-Mental State Examination\
**MRI** Magnetic resonance imaging\
**MSE** Mental status examination\
**NIMH** National Institute of Mental Health\
**NS** Nervous system\
**OMO** Ongoing military operations\
**OTC** Over-the-counter\
**PCL-C** PTSD Checklist -- Civilian Version\
**PCL-M** PTSD Checklist -- Military Version\
**PCL-S** PTSD Checklist -- Stressor Specific Version\
**PCP** Primary care provider\
**PE** Physical examination\
**PE (Interventions)** Prolonged Exposure\
**PIES** Proximity, Immediacy, Expectancy, Simplicity\
**PTSD** Post-traumatic Stress Disorder\
**QE** Quality of evidence\
**RCS** Readjustment Counseling Services\
**RCT** Randomized controlled trial\
**RTD** Return-to-duty\
**SC** Supportive Counseling\
**SIADH** Syndrome of inappropriate antidiuretic hormone\
**SIPU** Specialized Inpatient PTSD Unit\
**SIT** Stress Inoculation Therapy\
**SM** Service member\
**SR** Strength of recommendation\
**SSRI** Selective Serotonin Reuptake Inhibitors\
**SUD** Substance Use Disorder\
**SUNY** State University of New York\
**TCAs** Tricyclic Antidepressants\
**TSH** Thyroid Stimulating Hormone\
**USPSTF** U.S. Preventive Service Task Force\
**VA** Veterans Affairs\
**VAMC** Veterans Affairs Medical Center\
**VHA** Veterans Health Administration

**Rating Scheme for the Strength of the Evidence**:

**I** At least one properly done randomized controlled trial (RCT)\
**II-1** Well designed controlled trial without randomization\
**II-2** Well designed cohort or case-control analytic study\
**II-3** Multiple time series, dramatic results of uncontrolled
experiment\
**III** Opinion of respected authorities, case reports, and expert
committees

**Overall Quality**

**Good** \-- High grade evidence (I or II-1) directly linked to health
outcome\
**Fair** \-- High grade evidence (I or II-1) linked to intermediate
outcome; *or* moderate grade evidence (II-2 or II-3) directly linked to
health outcome\
**Poor** \-- Level III evidence or no linkage of evidence to health
outcome

**Net Effect of the Intervention**

**Substantial** \-- More than a small relative impact on a frequent
condition with a substantial burden of suffering; *or* a large impact on
an infrequent condition with a significant impact on the individual
patient level

**Moderate** \-- A small relative impact on a frequent condition with a
substantial burden of suffering; *or* a moderate impact on an infrequent
condition with a significant impact on the individual patient level

**Small** \-- A negligible relative impact on a frequent condition with
a substantial burden of suffering; *or* a small impact on an infrequent
condition with a significant impact on the individual patient level

**Zero or Negative** \-- Negative impact on patients; *or* no relative
impact on either a frequent condition with a substantial burden of
suffering; *or* an infrequent condition with a significant impact on the
individual patient level.

**Final Grade of Recommendation is determined according to the following
chart:**

  ------------------------------------------------------------------------------
  ** **             **The net benefit                               
                    of the                                          
                    intervention**                                  
  ----------------- ----------------- ----------------- ----------- ------------
  **Quality of      **Substantial**   **Moderate**      **Small**   **Zero or
  Evidence**                                                        Negative**

  **Good**          **A**             **B**             **C**       **D**

  **Fair**          **B**             **B**             **C**       **D**

  **Poor**          **I**             **I**             **I**       **I**
  ------------------------------------------------------------------------------

**Rating Scheme for the Strength of the Recommendations**

**A** A strong recommendation that the intervention is always indicated
and acceptable\
**B** A recommendation that the intervention may be useful/effective\
**C** A recommendation that the intervention may be considered\
**D** A recommendation that a procedure may be considered not
useful/effective, or may be harmful\
**I** Insufficient evidence to recommend for or against -- the clinician
will use clinical judgment

#### CLINICAL ALGORITHM(S)

Clinical algorithms are provided in the original guideline document for:

-   Initial Evaluation and Triage

-   Acute Stress Reaction (ASR)

-   Combat and Ongoing Operation Stress Reaction (COSR)

-   Acute Stress Disorder (ASD) and Post-Traumatic Stress Disorder
    (PTSD) in Primary Care

-   Management of PTSD in Mental Health Specialty Care

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### REFERENCES SUPPORTING THE RECOMMENDATIONS

[References open in a new
window](http://www.guideline.gov/summary/select_ref.aspx?doc_id=5187)

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is identified and graded for selected
recommendations (see \"Major Recommendations\").

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

By providing effective assistance to persons who have suffered a trauma,
some of those persons might not go on to develop post-traumatic stress
disorder (PTSD).

#### POTENTIAL HARMS

A detailed recounting of a traumatic experience may cause further
distress to the patient and is not advisable unless a provider has been
trained and is able to support the patient through this experience.

**Pharmacological Adverse Effects**

Note: See Table 4 of Module 1 -- *Treatment Interventions for PTSD --
for detailed list of drug adverse effects and cautions*.

-   Selective serotonin reuptake inhibitors (SSRIs) (fluoxetine,
    paroxetine, sertraline, fluvoxamine, citalopram): nausea, headache,
    sexual dysfunction, hyponatremia/syndrome of inappropriate
    antidiuretic hormone (SIADH), serotonin syndrome

-   Tricyclic antidepressants (imipramine, amitriptyline, desipramine,
    nortriptyline, protriptyline, clomipramine): anticholinergic
    effects, orthostatic hypotension, increased heart rate, ventricular
    arrhythmias

-   Monoamine oxidase inhibitors (phenelzine, tranylcypromine):
    hypertensive crisis with drug/tyramine interactions, bradycardia,
    orthostatic hypotension, insomnia

-   Sympatholytics: propranolol -- hypotension, bronchospasm,
    bradycardia; prazosin -- first dose syncope

-   Novel antidepressants: trazodone and nefazodone -- sedation, rare
    priapism; venlafaxine -- hypertension in patients with preexisting
    hypertension; nefazodone -- hepatoxicity

-   Anticonvulsants: carbamazepine -- leukopenia, SIADH, drowsiness,
    ataxia; gabapentin -- sedation, ataxia; lamotrigine -
    Stevens-Johnson syndrome, fatigue; topiramate -- secondary angle
    closure glaucoma, sedation, dizziness, ataxia; valproate --
    nausea/vomiting, sedation, ataxia, thrombocytopenia

-   Benzodiazepines (clonazepam, lorazepam, alprazolam, diazepam):
    sedation, memory impairment, ataxia, dependence

-   Typical antipsychotics (chlorpromazine, haloperidol, thioridazine):
    sedation, orthostatic hypotension (with chlorpromazine and
    thorazine), akathisia, dystonia, drug-induced parkinsonism, tardive
    dyskinesia , neuroleptic malignant syndrome, QTc changes

-   Atypical antipsychotics (olanzapine, quetiapine, risperidone):
    sedation, weight gain, neuroleptic malignant syndrome, akathisia (at
    high doses), drug-induced parkinsonism, especially with doses \>6
    mg/d

-   Non-benzodiazepine hypnotics (zaleplon, zolpidem): sedation, ataxia,
    rebound insomnia

-   Non-benzodiazepine anti-anxiety (buspirone): nausea, headache

### CONTRAINDICATIONS

#### CONTRAINDICATIONS

-   Selective serotonin reuptake inhibitors (SSRIs) (fluoxetine,
    paroxetine, sertraline, fluvoxamine, citalopram) are contraindicated
    with MAO inhibitor use within 14 days and relatively contraindicated
    in patients with hypersensitivity.

-   Tricyclic Antidepressants (imipramine, amitriptyline, desipramine,
    nortriptyline, protriptyline, clomipramine) are contraindicated with
    monoamine oxidase inhibitor (MAOI) use within 14 days, and acute
    myocardial infarction within 3 months, and relatively
    contraindicated in patients with coronary artery disease and
    prostatic enlargement. Clomipramine is contraindicated in patients
    with seizure disorder.

-   Monoamine Oxidase Inhibitors (MAOI)(phenelzine, tranylcypromine) are
    contraindicated with use of all antidepressants within 7 days of
    start of MAOI, except fluoxetine is 5 weeks, and use of central
    nervous system stimulants and decongestants.

-   Propranolol: Sinus bradycardia, congestive heart failure are
    contraindications.

-   Novel antidepressants (bupropion, nefazodone, trazodone,
    venlafaxine) are contraindicated with MAOI use within 14 days, and
    bupropion.

-   Anticonvulsants: Carbamazepine is contraindicated in patients with
    bone marrow suppression, particularly leukopenia. Gabapentin is
    contraindicated in those with renal impairment. Lamotrigine is
    contraindicated in patients who experience increased rash with
    valproate (max. dose of 200 mg). Topiramate is contraindicated in
    patients with hepatic impairment, and valproate with impaired liver
    function and thrombocytopenia.

-   Benzodiazepines (clonazepam, lorazepam, alprazolam, diazepam) should
    be used with caution in elderly patients and patients with impaired
    liver function, and there is a risk of abuse in patients with
    history of substance abuse.

-   Typical antipsychotics (chlorpromazine, haloperidol, thioridazine)
    are contraindicated in patients with Parkinson´s disease and QTc
    prolongation.

-   Atypical antipsychotics (olanzapine, quetiapine, risperidone) are
    relatively contraindicated in Parkinson´s disease.

-   Non-benzodiazepine hypnotics (zaleplon, zolpidem) should be used
    with caution with alcohol/drug abuse history and with caution in
    elderly patients with liver dysfunction.

-   Non-benzodiazepine anti-anxiety (buspirone) is contraindicated with
    MAOI use within 14 days.

-   Contraindications for Cognitive Therapy have not been empirically
    established, but may include psychosis, severe brain damage, or
    severe intellectual impairment.

-   Patients living in dangerous circumstances (e.g., domestic violence
    or a threatening environment) are not candidates for Exposure
    Therapy until their security can be assured. Other contraindications
    for Exposure Therapy have not been confirmed in empirical research,
    but may include health problems that preclude exposure to intense
    physiological arousal, current suicidal ideation, substance abuse
    not in stable remission, comorbid psychosis, or lack of motivation
    to undergo the treatment.

-   Contraindications for Group Therapy include active psychosis, severe
    organicity or limited cognitive capacity, pending litigation, or
    compensation seeking.

-   There are a number of contraindications for using traditional
    hypnotic techniques in the treatment of PTSD:

    -   In the rare cases of individuals who are refractory or minimally
        responsive to suggestions, hypnotic techniques may not be the
        best choice, because there is some evidence that hypnotizability
        is related to treatment outcome efficacy.

    -   Some PTSD patients may be reluctant to undergo hypnosis, either
        because of religious belief or other reasons. If the resistance
        is not cleared after dispelling mistaken assumptions, other
        suggestive techniques can be tried, including emotional
        self-regulation therapy (ESRT), which is done with open eyes and
        uses sensory recall exercises rather than a hypnotic induction.

    -   For patients who have low blood pressure or are prone to fall
        asleep, hypnotic procedures such as \"alert hand,\" which
        emphasize alertness and activity rather than relaxation, may be
        substituted.

-   Psychosocial rehabilitation techniques are contraindicated when
    client and clinician conclude that the problems are resolved.

-   Marriage counseling is typically contraindicated in cases of
    domestic violence, until the batterer has been successfully
    (individually) rehabilitated.

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

Clinical practice guidelines, which are increasingly being used in
health care, are seen by many as a potential solution to inefficiency
and inappropriate variations in care. Guidelines should be
evidenced-based as well as based upon explicit criteria to ensure
consensus regarding their internal validity. However, it must be
remembered that the use of guidelines must always be in the context of a
health care provider\'s clinical judgment in the care of a particular
patient. For that reason, the guidelines may be viewed as an educational
tool analogous to textbooks and journals, but in a more user-friendly
tone.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

This guideline builds on Department of Defense (DoD) and Veterans
Affairs (VA) expertise to promote state-of-the-art assessment and
intervention. It is a tool designed for this time of trauma and
challenge. Parts of this Clinical Practice Guideline have already served
in Afghanistan and Iraq.

#### IMPLEMENTATION TOOLS

Clinical Algorithm\
Resources

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better\
Living with Illness\
Staying Healthy

#### IOM DOMAIN

Effectiveness\
Patient-centeredness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Veterans Health Administration, Department of Defense. VA/DoD clinical
practice guideline for the management of post-traumatic stress. Version
1.0. Washington (DC): Veterans Health Administration, Department of
Defense; 2004 Jan. Various p. \[479 references\]

#### ADAPTATION

The guideline draws from other evidence based guidelines that were
available to the Working Group:

-   Effective Treatments for PTSD: Practice Guidelines from the
    International Society for Traumatic Stress Studies. Foa EB, Keane
    TM, Friedman MJ (Eds) 2000

-   The Expert Consensus Guideline Series: Treatment of Posttraumatic
    Stress Disorder. Foa EB, et al., 1999

-   Mental Health and Mass Violence: Evidenced-Based Early Psychological
    Intervention for Victims/Survivors of Mass Violence. A Workshop to
    Reach Consensus on Best Practices. National Institute of Mental
    Health 2002. NIH Publication No. 02-5138. Washington, D.C.: U.S.
    Government Printing Office.
    (<http://www.nimh.nih.gov/publicat/massviolence.pdf>)

#### DATE RELEASED

2004 Jan

#### GUIDELINE DEVELOPER(S)

Department of Defense - Federal Government Agency \[U.S.\]\
Department of Veterans Affairs - Federal Government Agency \[U.S.\]\
Veterans Health Administration - Federal Government Agency \[U.S.\]

#### SOURCE(S) OF FUNDING

United States Government

#### GUIDELINE COMMITTEE

The Management of Post-traumatic Stress Working Group

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Working Group Members*: Bruce Alexander, PharmD, BCPP, Clinical
Pharmacist Specialist, Iowa City Medical Center; Lt Col Paul V. Bennett,
APRN, BC, MDOS Squadron Commander, Tinker Air Force Base/72d Medical
Group; Stewart Brown, PhD, Clinical Psychologist, Team Leader, Boulder
Vet Center; Oneil Brown, Administrative Assistant, ACS Federal
Healthcare, Inc.; Jamie Buth, MD, Director, Ambulatory & Primary Care
Service Line, VAMC New Orleans; Marian Butterfield, MD,
Physician/Psychiatrist, Durham VAMC; Maj Steven J. Byrnes, PsyD,
Psychologist, Wright Patterson Medical Center; Juanita M. Celie, MSW,
Deputy Director of Social Work Training Program, 89 Medical Group; Maria
L. Crane, PsyD, Clinical Psychologist, Team Leader, Readjustment
Counseling Service; LTC Bruce E. Crow, PsyD, Chief, Department of
Psychology, Madigan Army Medical Center; Kathy Dolter, PhD, LTC, Chief,
Outcomes Management & Practice Guideline Project Officer, Quality
Management, USA MEDCOM; LTC Charles C. Engel, MD, MPH, Chief, Deployment
Health Clinical Center, DoD Deployment Health Clinical Center; Matthew
Friedman, MD, PhD, Executive Director, National Center for PTSD, VA &
Regional Office Ctre.; James Garrett, PhD, Clinical Psychologist, Team
Leader, Albany Vet Center; LTJG Leah Y Geislinger, MA, OTR/L,
Occupational Therapist, Naval Medical Center Portsmouth; MAJ Gary A.
Hazlett, PsyD, Clinical Psycholgoy, U.S. Army Special Operations
Command; Sarah Ingersoll, Project Manager, ACS Federal Healthcare, Inc.;
CAPT Robert L. Koffman, MD, MPH, 2d MAW Wing Surgeon, 2d Marine Aircraft
Wing; Harold S. Kudler, MD, Mental Health Coordinator, VISN 6, Durham
VAMC; MAJ Willis T. Leavitt, Psychiatry, Assistant Project Officer,
Operation, Solace, Operation Solace/WRAMC/U.S. Army; LTC Cassandra L.
Lewis, MS, OTR, Chief, Occupational Therapy, Brooke Army Medical Center;
CDR Steven E. Linnville, PhD, Head, Educational & Organizational
Assessment, Naval School of Health Sciences Bethesda; Joanne Marko, MS,
Senior Consultant, ACS Federal Healthcare, Inc.; Miles McFall, PhD,
Director, PTSD Programs, VA PSHCS, VA Puget Sound Health Care System;
LTC Muriel Mosley, MSW, Chief, Family Advocacy Training Section, Academy
of Health Sciences; John Oliver, MDiv, DMin, Chaplain/Clinical Pastoral
Education, Supervisor, ACPE, Durham VAMC; Josef I. Ruzek, PhD, Associate
Director for Education, National Center for PTSD, VA Palo Alto Health
Care System; Maj Libby Schindler, PharmD, Clinical Pharmacist, 59th
Medical Wing, MTPS, Wilford Hall Medical Center; Donna Schoonover, RN,
EdD, Project Manager, Employee Education System; Jonathan Shay, MD, PhD,
Department of Veterans Affairs OPC Boston; Maj Dana L. Simpson, MD,
Family Practice Residency Faculty, Andrews AFB; Steven Southwick, MD,
Clinical Neuroscience, National Center PTSD, VA CT Health Care System;
COL James W. Stokes, MD, Combat Stress Control Program Officer,
Headquarters US Army Medical Command; Oded Susskind, MPH, Medical
Education Consultant; Sara Thomas, Consultant, ACS Federal Healthcare,
Inc.; Jane F. Vieira, DMin, Special Assistant for Pastoral Care, Bureau
of Medicine and Surgery; Debby Walder, RN, MSN, Director of Quality and
Performance, Department of Veterans Affairs; Lt Col Randon Welton, MD,
Medical Director, LSSC, Willford Hall, Willford Hall Medical Center; LTC
Stacey Young-McCaughan RN, PhD, US Army Nurse Corps, Chief, Performance
Improvement & Outcomes Management

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

#### GUIDELINE AVAILABILITY

Electronic copies: Available in Portable Document Format (PDF) from the
[Department of Veterans Affairs Web
site](http://www.oqp.med.va.gov/cpg/PTSD/PTSD_Base.htm).

Print copies: Available from the Department of Veterans Affairs,
Veterans Health Administration, Office of Quality and Performance (10Q)
810 Vermont Ave. NW, Washington, DC 20420.

#### AVAILABILITY OF COMPANION DOCUMENTS

-   Various companion documents are available from the: [Veterans Health
    Administration (VHA) Web
    site](http://www.oqp.med.va.gov/cpg/PTSD/PTSD_Base.htm).

-   In addition, the [VHA Web
    site](http://www.oqp.med.va.gov/cpg/PTSD/PTSD_Base.htm) provides
    references to related guidelines, performance measures, and other
    resources.

-   Guideline for guidelines. Draft. Washington (DC): Veterans Health
    Administration, Department of Veterans Affairs. Available at: [VHA
    Web site](http://www.oqp.med.va.gov/cpg/policy.asp).

Print copies: Department of Veterans Affairs, Veterans Health
Administration, Office of Quality and Performance (10Q) 810 Vermont Ave.
NW, Washington, DC 20420.

The following is also available:

-   Putting clinical practice guidelines to work \[online tutorial\].
    Available from the [Department of Veterans Affairs Web
    site](http://www.oqp.med.va.gov/Training/WWW/010000000010.html).

See also the following related QualityTool summaries on the Health Care
Innovations Exchange Web site:

-   [Department of Veterans Affairs/Department of Defense (VA/DoD)
    clinical practice guideline for the management of post traumatic
    stress acute stress reaction (ASR) module: pocket
    guide](http://innovations.ahrq.gov/content.aspx?id=1184)

-   [Management of post-traumatic stress in primary care: core module:
    initial evaluation and triage
    algorithm](http://innovations.ahrq.gov/content.aspx?id=1212)

-   [Department of Veterans Affairs/Department of Defense (VA/DoD)
    clinical practice guideline for the management of post traumatic
    stress: core module
    summary](http://innovations.ahrq.gov/content.aspx?id=1214)

-   [Department of Veterans Affairs/Department of Defense (VA/DoD)
    clinical practice guideline for the management of post-traumatic
    stress: module A1
    summary](http://innovations.ahrq.gov/content.aspx?id=1200)

-   [Management of post-traumatic stress: module A1: acute stress
    reaction (2-4 days after trauma)
    algorithm](http://innovations.ahrq.gov/content.aspx?id=1193)

-   [Management of post-traumatic stress: module A-2: combat/ongoing
    military operation stress reaction (COSR)
    algorithm](http://innovations.ahrq.gov/content.aspx?id=1218)

-   [Department of Veterans Affairs/Department of Defense (VA/DoD)
    clinical practice guideline for the management of post-traumatic
    stress: module A2
    summary](http://innovations.ahrq.gov/content.aspx?id=1194)

-   [Department of Veterans Affairs/Department of Defense (VA/DoD)
    clinical practice guideline for the management of post-traumatic
    stress: module B
    summary](http://innovations.ahrq.gov/content.aspx?id=1195)

-   [Management of post-traumatic stress: module B: management of acute
    stress disorder/post-traumatic stress disorder (ASD/PTSD) in primary
    care algorithm](http://innovations.ahrq.gov/content.aspx?id=1199)

-   [Department of Veterans Affairs/Department of Defense (VA/DoD)
    clinical practice guideline for the management of post traumatic
    stress: module C
    summary](http://innovations.ahrq.gov/content.aspx?id=1215)

-   [Management of post-traumatic stress: module C: management of acute
    stress disorder/post-traumatic stress disorder (ASD/PTSD) in mental
    health specialty
    algorithm](http://innovations.ahrq.gov/content.aspx?id=1213)

-   [Department of Veterans Affairs/Department of Defense (VA/DoD)
    clinical practice guideline for the management of post traumatic
    stress: key points
    card](http://innovations.ahrq.gov/content.aspx?id=1207)

-   [Department of Veterans Affairs/Department of Defense (VA/DoD)
    clinical practice guideline for the management of post traumatic
    stress (PTSD) or acute stress disorder (ASD) in primary care module:
    pocket guide](http://innovations.ahrq.gov/content.aspx?id=1206)

-   [Department of Veterans Affairs/Department of Defense (VA/DoD)
    clinical practice guideline for the management of post traumatic
    stress: interventions module
    summary](http://innovations.ahrq.gov/content.aspx?id=1219)

#### PATIENT RESOURCES

None available

#### NGC STATUS

This NGC summary was completed by ECRI on August 31, 2004. The
information was verified by the guideline developer on November 15,
2004. This summary was updated by ECRI on August 15, 2005, following the
U.S. Food and Drug Administration advisory on antidepressant
medications. This summary was updated by ECRI on October 3, 2005,
following the U.S. Food and Drug Administration advisory on Paxil
(paroxetine). This summary was updated by ECRI on December 12, 2005,
following the U.S. Food and Drug Administration advisory on Paroxetine
HCL - Paxil and generic paroxetine. This summary was updated by ECRI on
May 31, 2006 following the U.S. Food and Drug Administration advisory on
Paxil (paroxetine hydrochloride). This summary was updated by ECRI on
November 22, 2006, following the FDA advisory on Effexor (venlafaxine
HCl). This summary was updated by ECRI Institute on April 30, 2007,
following the FDA advisory on Sedative-hypnotic drug products. This
summary was updated by ECRI Institute on November 6, 2007, following the
U.S. Food and Drug Administration advisory on Antidepressant drugs. This
summary was updated by ECRI Institute on January 10, 2008, following the
U.S. Food and Drug Administration advisory on Carbamazepine.

#### COPYRIGHT STATEMENT

No copyright restrictions apply.

### DISCLAIMER

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Date Modified: 11/3/2008