VA/DoD Clinical Practice Guidelines
Management of PosttraumaticStress Disorder andAcute Stress Disorder

Provider Summary
Version 4.0 | 2023

VA/DoD CLINICALPRACTICE GUIDELINE FOR
MANAGEMENT OF POSTTRAUMATIC
STRESS DISORDER AND ACUTESTRESS DISORDER
Department of Veterans Affairs
Department of Defense

Provider Summary
QUALIFYING STATEMENTS
The Department of Veterans Affairs (VA) and the Department of Defense (DoD)
guidelines are based on the best information available at the time of publication. The
guidelines are designed to provide information and assist decision making. They are notintended to define a standard of care and should not be construed as one. Neither should
they be interpreted as prescribing an exclusive course of management.
This clinical practice guideline (CPG) is based on a systematic review (SR) of both clinicaland epidemiological evidence. Developed by a panel of multidisciplinary experts, it
provides a clear explanation of the logical relationships between various care options andhealth outcomes while rating both the quality of the evidence and the strength of therecommendation.
Variations in practice will inevitably and appropriately occur when providers consider theneeds of individual patients, available resources, and limitations unique to an institution ortype of practice. Therefore, every health care professional using these guidelines is
responsible for evaluating the appropriateness of applying them in the setting of any
particular clinical situation with a patient-centered approach.
These guidelines are not intended to represent VA or DoD policies. Further, inclusion ofrecommendations for specific testing, therapeutic interventions, or both within theseguidelines does not guarantee coverage of civilian sector care.
Version 4.0 - 2023

VA/DoD Clinical Practice Guideline for Management of PTSD – Provider Summary

Table of Contents
Introduction ........................................................................................................................ 1
Highlights in this Guideline .............................................................................................. 2
Recommendations ............................................................................................................. 3
Scope of the CPG............................................................................................................... 7
Guideline Development Team .......................................................................................... 7
Patient-centered Care........................................................................................................ 8
Shared Decision Making ................................................................................................... 8
Algorithm ............................................................................................................................ 9
Module A: Acute Stress Reaction/Disorder ............................................................... 10
Module B: Assessment and Diagnosis of Posttraumatic Stress Disorder ................ 11
Module C: Management of Posttraumatic Stress Disorder ....................................... 12
Pharmacotherapy Dosing Table..................................................................................... 19
Methods ............................................................................................................................ 20
References........................................................................................................................ 22

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VA/DoD Clinical Practice Guideline for Management of PTSD – Provider Summary

Introduction
The VA and DoD Evidence-Based Practice Work Group (EBPWG) was established andfirst chartered in 2004, with a mission to advise the VA/DoD Health Executive Committee“on the use of clinical and epidemiological evidence to improve the health of the
population . . .” across the Veterans Health Administration (VHA) and Military Health
System (MHS), by facilitating the development of CPGs for the VA and DoD
populations.(1) Development and update of VA/DoD CPGs is funded by VA Evidence
Based Practice, Office of Quality and Patient Safety. The system-wide goal of evidencebased CPGs is to improve patient health and wellbeing.
In 2017, VA and DoD published a CPG for Management of Posttraumatic Stress Disorderand Acute Stress Disorder (2017 VA/DoD PTSD CPG), which was based on evidence
reviewed through March 2016. Since the release of that CPG, the evidence base on
PTSD has expanded. Consequently, the EBPWG initiated the update of the 2017
VA/DoD PTSD CPG in 2022. This updated CPG’s use of Grading of Recommendations
Assessment, Development, and Evaluation (GRADE) approach reflects a more rigorous
application of the methodology than previous iterations.(2) Therefore, the strength ofsome recommendations might have been modified because of the confidence in thequality of the supporting evidence (see Evidence Quality and Recommendation Strength
in the full VA/DoD PTSD CPG).
This CPG provides an evidence-based framework for evaluating and managing care forindividuals with posttraumatic stress disorder (PTSD) or acute stress disorder (ASD)
toward improving clinical outcomes. Successful implementation of this CPG will:·

Assess the patient’s condition and collaborate with the patient, family, andcaregivers to determine optimal management of patient care;·

Emphasize the use of patient-centered care and shared decision making;·

Minimize preventable complications and morbidity; and·Optimize individual health outcomes and quality of life (QoL).

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VA/DoD Clinical Practice Guideline for Management of PTSD – Provider Summary

Highlights in this Guideline
The 2023 VA/DoD PTSD CPG reflects a more rigorous application of the GRADE
methodology than the 2017 VA/DoD PTSD CPG. This approach has resulted in the
exclusion or downgrading of studies included in previous versions of this CPG and has
impacted the strength of some recommendations (e.g., Strong for downgraded to Weakfor), despite a similar evidence base. For additional information on GRADE or CPG
methodology, see Appendix A in the full CPG.
In the 2017 VA/DoD PTSD CPG, trauma-focused psychotherapies were evaluated as aclass that included Cognitive Processing Therapy (CPT), Eye Movement Desensitization
and Reprocessing (EMDR), and Prolonged Exposure (PE). In the 2023 CPG, theevidence on trauma-focused psychotherapies was reviewed for each treatment
individually, rather than as a class, for comparison with medications. This review,combined with the more rigorous application of GRADE and accumulated new evidence,
resulted in the downgrading of some specific treatments.
Significant changes to the strength of the recommendations include the following.
·

Downgrading of some trauma-focused psychotherapies that previously received aStrong for recommendation (Brief Eclectic Psychotherapy and Narrative Exposure
Therapy [NET] were downgraded to Neither for nor against [Recommendation 10],and Ehlers’ Cognitive Therapy [CT] for PTSD and written narrative exposure, now
called Written Exposure Therapy [WET], was downgraded to Weak for[Recommendation 9]).

·Downgrading of some non-trauma-focused psychotherapies that previously
received a Weak for recommendation (Stress Inoculation Training [SIT] andInterpersonal Psychotherapy [IPT] were downgraded to Neither for nor against[Recommendation 10]).

·

Downgrading of one medication that previously received a Strong forrecommendation (Fluoxetine was downgraded to Neither for nor against[Recommendation 16]).

·

Downgrading of some medications that previously received a Weak forrecommendation (Nefazodone, phenelzine, and imipramine were downgraded to
Neither for nor against [Recommendation 16]).

·

Adding Weak for recommendations for prazosin for nightmares (Recommendation32) and Mindfulness-Based Stress Reduction® (MBSR) for overall PTSD
symptoms (Recommendation 26).

Other changes in the CPG include the following.
·

Updated algorithm for screening and treatment of ASD and PTSD·

Greater attention to discussing the generalizability of evidence to subgroups basedon gender identity, sexuality, race, ethnicity, age, and other patient characteristics

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VA/DoD Clinical Practice Guideline for Management of PTSD – Provider Summaryand clearer delineation of complementary, integrative, and alternative healthtreatment·

Updated recommendations on research needed to strengthen future guidelines

Recommendations
The evidence-based clinical practice recommendations listed (see Table 1) were madeusing a systematic approach considering four domains as per the GRADE approach (seeSummary of Guideline Development Methodology in the full VA/DoD CPG). These
domains include confidence in the quality of the evidence, balance of desirable andundesirable outcomes (i.e., benefits and harms), patient values and preferences, andother implications (e.g., resource use, equity, acceptability).
Table 1. Evidence-based Clinical Practice Recommendations with Strength and Category

Selective Preventionof PTSD
Indicated
Prevention of PTSD

Prevention of PTSD

Assessment andDiagnosis of PTSD

SubTopic topic

June 2023#

Recommendation

Strengtha

Categoryb

1.

When screening for PTSD, we suggest using the Primary
Care PTSD Screen for DSM-5.

Weak for

Reviewed,
New-replaced2.

For confirmation of the diagnosis of PTSD, we suggest using
a validated structured clinician-administered interview, suchas the Clinician-Administered PTSD Scale or PTSD
Symptom Scale - Interview Version.

Weak for

Reviewed,
New-replaced3.

To detect changes in PTSD symptom severity over time, wesuggest the use of a validated instrument, such as the PTSD
Checklist for DSM-5, or a structured clinician-administeredinterview, such as the Clinician-Administered PTSD Scale.

Weak for

Reviewed,
New-replaced

4.

For the prevention of PTSD among individuals who havebeen exposed to trauma, there is insufficient evidence torecommend for or against psychotherapy or
pharmacotherapy in the immediate post-trauma period.

Neither for Not Reviewed,
nor against
Amended5.

For the prevention of PTSD among patients diagnosed withacute stress disorder, we suggest trauma-focused cognitive
behavioral psychotherapy.

Weak for

Reviewed,
New-replaced

6.

For the prevention of PTSD among patients diagnosed withacute stress reaction/acute stress disorder, there isinsufficient evidence to recommend for or against any
pharmacotherapy.

Neither for
nor against

Reviewed,
New-replaced

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VA/DoD Clinical Practice Guideline for Management of PTSD – Provider Summary

Psychotherapy

Treatment of PTSD

Treatment
Selection

SubTopic topic

June 2023#

Recommendation

Strengtha

Categoryb

7.

We recommend individual psychotherapies, listed in
Recommendation 8, over pharmacologic interventions for thetreatment of PTSD.

Strong for

Reviewed,
New-replaced8.

We recommend the individual, manualized trauma-focused
psychotherapies for the treatment of PTSD: Cognitive
Processing Therapy, Eye Movement Desensitization andReprocessing, or Prolonged Exposure.

Strong for

Reviewed,
New-replaced

9.

We suggest the following individual, manualized
psychotherapies for the treatment of PTSD: Ehlers’ Cognitive
Therapy for PTSD, Present-Centered Therapy, or Written
Exposure Therapy.

Weak for

Reviewed,
New-replaced

10.

There is insufficient evidence to recommend for or against
the following individual psychotherapies for the treatment of
PTSD: Accelerated Resolution Therapy, Adaptive Disclosure,Acceptance and Commitment Therapy, Brief Eclectic
Psychotherapy, Dialectical Behavior Therapy, Emotional
Freedom Techniques, Impact on Killing, Interpersonal
Psychotherapy, Narrative Exposure Therapy, Prolonged
Exposure in Primary Care, psychodynamic therapy,
psychoeducation, Reconsolidation of Traumatic Memories,
Seeking Safety, Stress Inoculation Training, Skills Training in
Affective and Interpersonal Regulation, Skills Training in
Affective and Interpersonal Regulation in Primary Care,supportive counseling, Thought Field Therapy, TraumaInformed Guilt Reduction, or Trauma Management Therapy.

Neither for
nor against

Reviewed,
New-replaced

11.

There is insufficient evidence to recommend using individualcomponents of manualized psychotherapy protocols over, orin addition to, the full therapy protocol for the treatment of
PTSD.

Neither for Reviewed, Not
nor against
Changed

12.

There is insufficient evidence to recommend for or against
any specific manualized group therapy for the treatment of
PTSD.

Neither for
nor against

Reviewed,
New-replaced

13.

There is insufficient evidence to recommend using grouptherapy as an adjunct for the primary treatment of PTSD.

Neither for
nor against

Reviewed,
New-replaced

14.

There is insufficient evidence to recommend for or against
the following couples therapies for the treatment of PTSD:
Behavioral Family Therapy, Structured Approach Therapy, or
Cognitive Behavioral Conjoint Therapy.

Neither for Reviewed, Not
nor against
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VA/DoD Clinical Practice Guideline for Management of PTSD – Provider Summary

Recommendation

Strengtha

Categoryb

Pharmacotherapy

15.

We recommend paroxetine, sertraline, or venlafaxine for thetreatment of PTSD.

Strong for

Reviewed,
New-replaced

16.

There is insufficient evidence to recommend for or against
amitriptyline, bupropion, buspirone, citalopram,
desvenlafaxine, duloxetine, escitalopram, eszopiclone,
fluoxetine, imipramine, mirtazapine, lamotrigine, nefazodone,olanzapine, phenelzine, pregabalin, rivastigmine, topiramate,or quetiapine for the treatment of PTSD.

Neither for
nor against

Reviewed,
New-replaced

Pharmacotherapy (cont.)

17.

There is insufficient evidence to recommend for or against
psilocybin, ayahuasca, dimethyltryptamine, ibogaine, orlysergic acid diethylamide for the treatment of PTSD.

Neither for
nor against

Reviewed,
New-added

18.

We suggest against divalproex, guanfacine, ketamine,prazosin, risperidone, tiagabine, or vortioxetine for thetreatment of PTSD.

Weak
against

Reviewed,
New-replaced19.

We recommend against benzodiazepines for the treatment of
PTSD.

Strongagainst

Reviewed,
New-replaced20.

We recommend against cannabis or cannabis derivatives forthe treatment of PTSD.

Strongagainst

Reviewed,
Amended21.

There is insufficient evidence to recommend for or against
the combination or augmentation of psychotherapy (seeRecommendation 8 and Recommendation 9) or medications(see Recommendation 15) with any psychotherapy or
medication for the treatment of PTSD (see Recommendation
22 for antipsychotic medications and Recommendation 23 for
3,4-methylenedioxymethamphetamine).

Neither for
nor against

Reviewed,
New-replaced22.

We suggest against aripiprazole, asenapine, brexpiprazole,
cariprazine, iloperidone, lumateperone, lurasidone,olanzapine, paliperidone, quetiapine, risperidone, or
ziprasidone for augmentation of medications for the treatment
of PTSD.

Weakagainst

Reviewed,
New-replaced

23.

There is insufficient evidence to recommend for or against
3,4-methylenedioxymethamphetamine assisted
psychotherapy for the treatment of PTSD.

Neither for
nor against

Reviewed,
New-added

24.

There is insufficient evidence to recommend for or against
the following somatic therapies for the treatment of PTSD:
capnometry-assisted respiratory therapy, hyperbaric oxygentherapy, neurofeedback, NightWare©, repetitive transcranial
magnetic stimulation, stellate ganglion block, or transcranial
direct current stimulation.

Neither for
nor against

Reviewed,
New-replaced25.

We suggest against electroconvulsive therapy or vagus nerve
stimulation for treatment of PTSD.

Weak
against

Reviewed,
New-replaced

Augmentation Therapy#

Non-pharmacologic
Biological Treatments

Treatment of PTSD (cont.)

SubTopic topic

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VA/DoD Clinical Practice Guideline for Management of PTSD – Provider Summary

Complementary, Integrative, and Alternative
Approaches

Treatment of PTSD with
Co-Occurring Conditions

Treatment ofNightmares

Technology-based
Treatment

Treatment of PTSD (cont.)

SubTopic topicab#

Recommendation

Strengtha

Categoryb

26.

We suggest Mindfulness-Based Stress Reduction® for thetreatment of PTSD.

Weak for

Reviewed,
New-replaced

27.

There is insufficient evidence to recommend for or against
the following mind-body interventions for the treatment of
PTSD: acupuncture, Cognitively Based Compassion Training
Veteran version, creative arts therapies (e.g., music, art,
dance), guided imagery, hypnosis or self-hypnosis, Loving
Kindness Meditation, Mantram Repetition Program,
Mindfulness-Based Cognitive Therapy, other mindfulness
trainings (e.g., integrative exercise, Mindfulness-Based
Exposure Therapy, brief mindfulness training), relaxation
training, somatic experiencing, tai chi or qigong,Transcendental Meditation®, and yoga.

Neither for
nor against

Reviewed,
New-replaced

28.

There is insufficient evidence to recommend for or against
the following interventions for the treatment of PTSD:
Neither forrecreational therapy, aerobic or non-aerobic exercise, animalnor against
assisted therapy (e.g., canine, equine), and natureexperiences (e.g., fishing, sailing).

Reviewed,
New-replaced29.

We recommend secure video teleconferencing to deliver
treatments in Recommendation 8 and Recommendation 9
when that therapy has been validated for use with video
teleconferencing or when other options are unavailable.

Strong for

Reviewed,
New-replaced

30.

There is insufficient evidence to recommend for or against
mobile apps or other self-help-based interventions for thetreatment of PTSD.

Neither for
nor against

Reviewed,
New-added

31.

There is insufficient evidence to recommend for or against
facilitated internet-based cognitive behavioral therapy for thetreatment of PTSD.

Neither for
nor against

Reviewed,
New-replaced

32.

We suggest prazosin for the treatment of nightmares
associated with PTSD.

Weak for

Reviewed,
Amended

33.

There is insufficient evidence to recommend for or against
the following treatments for nightmares associated with
PTSD: Imagery Rehearsal Therapy, Exposure Relaxation
and Rescripting Therapy, Imaging Rescripting andReprocessing Therapy, or NightWare.

Neither for
nor against

Reviewed,
New-added

34.

We suggest that the presence of co-occurring substance use
disorder and/or other disorder(s) not preclude treatments in
Recommendation 8 and Recommendation 9 for PTSD.

Weak for

Reviewed,
New-replaced

For additional information, see Grading Recommendations in the full VA/DoD PTSD CPG.
For additional information, see Recommendation Categorization and Appendix E in the full VA/DoD PTSD CPG.

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VA/DoD Clinical Practice Guideline for Management of PTSD – Provider Summary

Scope of the CPG
This CPG is based on published clinical evidence and related information available
through May 4, 2022. It is intended to provide general guidance on best evidence-based
practices (see Appendix A in the full VA/DoD PTSD CPG for additional information on theevidence review methodology). Although the CPG is intended to improve the quality ofcare and clinical outcomes (see Introduction in the full VA/DoD PTSD CPG), it is notintended to define a standard of care (i.e., mandated or strictly required care).
This CPG is intended for use by providers and others involved in the care of active duty
Service members and Veterans with PTSD.
The patient population of interest for this CPG is adults with PTSD or ASD caused by any
type of trauma who are eligible for care in VA or DoD health care delivery systems.

Guideline Development Team
Table 2. Guideline Work Group and Guideline Development Team
Organization

Name*
Paula P. Schnurr, PhD
Jessica L. Hamblen, PhD
Claire Collie, PhD
Matthew A. Fuller, PharmD, FASHP, BCPP
Paul E. Holtzheimer, MD, MS

Department of Veterans Affairs

Ursula Kelly, PhD, APRN, ANP-BC, PMHNP-BC, FAANP, FAAN
Ariel Lang, PhD, MPH
Sonya Norman, PhD
Katie Papke, LMSW, CAADC, CCTP, CHTVSPIsmene Petrakis, MD
Brian Shiner, MD, MPH
Ilse Wiechers, MD, MPP, MHS
Marija Kelber, PhD
Jonathan Wolf, MD

Department of Defense

Rachael Coller, PharmD
Kate McGraw, PhD
CAPT Joshua Morganstein, MD
David Riggs, PhD

James Sall, PhD, FNP-BC
VA Evidence Based Practice, Officeof Quality and Patient Safety
René Sutton, BS, HCA
Veterans Health Administration
Jennifer Ballard-Hernandez, DNP, RN, FNP-BC

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VA/DoD Clinical Practice Guideline for Management of PTSD – Provider Summary

Organization
Clinical Quality Improvement
ProgramDefense Health Agency

Name*
Elaine P. Stuffel, MHA, BSN, RN
Cynthia F. Villareal, BSN, RN
Isabella Alvarez, MA, BSN, RN
Clifford Goodman, PhD
Jennifer Weil, PhD

The Lewin Group

Peter Baroff, BA
Charlie Zachariades, MSc
Annie Zhang, BA
Jim Reston, PhD, MPH

ECRI

Amy Tsou, MD, MSc
Rebecca Rishar, BA, MLIS

Sigma Health Consulting

Duty First Consulting

Frances M. Murphy, MD, MPHJames G. Smirniotopoulos, MD
Kate Johnson, BS
Rachel Piccolino, BA*Additional contributor contact information is available in Appendix F in the full VA/DoD PTSD CPG.

Patient-centered CareIntended to consider patient needs and preferences, guideline recommendations
represent a whole/holistic health approach to care that is patient centered, culturally
appropriate, and available to people with limited literacy skills and physical, sensory, or
learning disabilities. VA/DoD CPGs encourage providers to use a patient-centered,
whole/holistic health approach (i.e., individualized treatment based on patient needs,
characteristics, and preferences). This approach aims to treat the particular condition
while also optimizing the individual’s overall health and wellbeing.
Regardless of the care setting, all patients should have access to individualized evidencebased care. Patient-centered care can decrease patient anxiety, increase trust inproviders, and improve treatment adherence.(3, 4) A whole/holistic health approach(https://www.va.gov/wholehealth/) empowers and equips individuals to meet theirpersonal health and wellbeing goals. Good communication is essential and should be
supported by evidence-based information tailored to each patient’s needs. An empathetic
and non-judgmental approach facilitates discussions sensitive to gender, culture,ethnicity, and other differences.

Shared Decision Making
This CPG encourages providers to practice shared decision making, a process in which
providers, patients, and patient care partners (e.g., family, friends, caregivers) consider
clinical evidence of benefits and risks as well as patient values and preferences to make
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VA/DoD Clinical Practice Guideline for Management of PTSD – Provider Summary

decisions regarding the patient’s treatment.(5) Shared decision making is emphasized in
Crossing the Quality Chasm, an Institute of Medicine, now NAM, report in 2001 (6) and isinherent within the whole/holistic health approach. Providers must be adept at presenting
information to their patients regarding individual treatments, expected risks, expected
outcomes, and levels or settings of care or both, especially where patient heterogeneity inweighing risks and benefits might exist. VHA and MHS have embraced shared decision
making. Providers are encouraged to use shared decision making to individualize
treatment goals and plans based on patient capabilities, needs, and preferences.

Algorithm
This CPG’s algorithm is designed to facilitate understanding of the clinical pathway anddecision-making process used in managing patients with PTSD. This algorithm format
represents a simplified flow of the management of patients with PTSD and helps foster
efficient decision making by providers. It includes·

Steps of care in an ordered sequence,·

Decisions to be considered,·

Decision criteria recommended, and·Actions to be taken.

The algorithm is a step-by-step decision tree. Standardized symbols display each step,and arrows connect the numbered boxes indicating the order in which the steps should
be followed.(7) Sidebars 1–11 provide more detailed information to assist in defining andinterpreting elements in the boxes.
Shape

Description
Rounded rectangles represent a clinical state or condition.
Hexagons represent a decision point in the process of care, formulated as aquestion that can be answered “Yes” or “No.”
Rectangles represent an action in the process of care.
Ovals represent a link to another section within the algorithm.

For alternative text descriptions of the algorithm, please refer to Appendix H in the full
VA/DoD CPG PTSD.

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VA/DoD Clinical Practice Guideline for Management of PTSD– Provider Summary

Module A: Acute Stress Reaction/Disorder

Abbreviations: ASR: Acute Stress Reaction; COSR: Combat and Operational Stress Reaction; CPG: clinical practiceguideline; DSM: Diagnostic and Statistical Manual of Mental Disorders; PTSD: Posttraumatic stress disorder;
VA: Veteran Affairs; DoD: Department of Defense.

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VA/DoD Clinical Practice Guideline for Management of PTSD– Provider Summary

Module B: Assessment and Diagnosis of Posttraumatic Stress Disorder

Abbreviations: CPG: clinical practice guideline; PTSD: Posttraumatic stress disorder; VA: Veteran Affairs;
DoD: Department of Defense.

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VA/DoD Clinical Practice Guideline for Management of PTSD– Provider Summary

Module C: Management of Posttraumatic Stress Disorder

Abbreviations: CPG: clinical practice guideline; PTSD: Posttraumatic stress disorder; VA: Veteran Affairs;
DoD: Department of Defense.

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Sidebar 1: Immediate Needs· Survival (including first aid and stabilizing physical condition), safety, and security· Food, hydration, shelter, and clothing· Sleep· Orientation· Communication with unit, family, friends, and community· Education and normalization of reactions to trauma

Sidebar 2: Assessment· History of trauma and mental health concerns· Symptoms· Consider screening for PTSD symptoms using the PC-PTSD-5 (Recommendation 1)· Medical status· Mental status, including suicidality (consult VA/DoD CPG for Assessment and Management of Patients
at Risk for Suicide,a as needed)· Functional status· Psychosocial status, including intimate and family relationships; financial problems; legal issues· Occupational performance· Substance use· Strengths, coping skills, and protective factorsa

See the VA/DoD CPG for the Assessment and Management of Patients at Risk for Suicide, available athttps://www.healthquality.va.gov/.
Abbreviations: PC-PTSD-5: Primary Care PTSD Screen for Diagnostic and Statistical Manual of Mental Disorders, Fifth
Edition; PTSD: posttraumatic stress disorder; VA: Veteran Affairs; DoD: Department of Defense.

Sidebar 3: DSM-5-TR Diagnostic Criteria for Acute Stress Disorder(8)Criterion A. Exposure to actual or threatened death, serious injury, or sexual violence in one (ormore) of the following ways:
1. Directly experiencing the traumatic event(s).
2. Witnessing, in person, the event(s) as it occurred to others.
3. Learning that the event(s) occurred to a close family member or close friend. Note: In cases ofactual or threatened death of a family member or friend, the event(s) must have been violent or
accidental.
4. Experiencing repeated or extreme exposure to aversive details of the traumatic event(s)(e.g., first responders collecting human remains, police officers repeatedly exposed to details ofchild abuse).
Note: This does not apply to exposure through electronic media, television, movies, or pictures unless thisexposure is work-related.

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Sidebar 3: DSM-5-TR Diagnostic Criteria for Acute Stress Disorder(8)Criterion B. Presence of nine (or more) of the following symptoms from any of the five categories
of intrusion, negative mood, dissociation, avoidance, and arousal, beginning or worsening after
the traumatic event(s) occurred:
Intrusion Symptoms
1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s).
2. Recurrent distressing dreams in which the content and/or affect of the dream are related to thetraumatic event(s).
3. Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic
event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme
expression being a complete loss of awareness of present surroundings.)
4. Intense or prolonged psychological distress or marked physiological reactions in response tointernal or external cues that symbolize or resemble an aspect of the traumatic event(s).
Negative Mood
5. Persistent inability to experience positive emotions (e.g., inability to experience happiness,satisfaction, or loving feelings).
Dissociative Symptoms
6. An altered sense of the reality of one’s surroundings or oneself (e.g., seeing oneself fromanother’s perspective, being in a daze, time slowing).
7. Inability to remember an important aspect of the event(s) (typically due to dissociative amnesia
and not to other factors such as head injury, alcohol, or drugs).
Avoidance Symptoms
8. Efforts to avoid distressing memories, thoughts, or feelings about or closely associated with thetraumatic event(s).
9. Efforts to avoid external reminders (people, places, conversations, activities, objects, situations)that arouse distressing memories, thoughts, or feelings about or closely associated with thetraumatic event(s).
Arousal Symptoms
10. Sleep disturbance (e.g., difficulty falling or staying asleep, restless sleep).
11. Irritable behavior and angry outbursts (with little or no provocation), typically expressed asverbal or physical aggression toward people or objects.
12. Hypervigilance.
13. Problems with concentration.
14. Exaggerated startle response.
Criterion C. Duration of the disturbance (symptoms in Criterion B) is 3 days to 1 month after
trauma exposure.
Note: Symptoms typically begin immediately after the trauma, but persistence for at least 3 days and up
to 1 month is needed to meet disorder criteria.
Criterion D. The disturbance causes clinically significant distress or impairment in social,occupational, or other important areas of functioning.
Criterion E. The disturbance is not attributable to the physiological effects of a substance (e.g.,
medication or alcohol) or another medical condition (e.g., mild traumatic brain injury) and is notbetter explained by a brief psychotic disorder.

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Sidebar 4: Acute Interventions for Acute Stress Disorder· Individual, manualized trauma-focused cognitive behavioral psychotherapy· Consider: Collaborative care or wellness-oriented activities

Sidebar 5: Acute Interventions for Acute Stress Response/Combat and OperationalStress Reaction· Education and normalization, acute symptom management, social support· Suggest: Brief cognitive behavioral psychotherapy

Sidebar 6: General Assessment· Complete comprehensive clinical assessment of presenting complaints and comorbid conditions· Perform safety, lethal means, and environmental assessment· Consider history and presenting complaints: mental health, medical, military, marital, family, substanceuse, social and spiritual life, functional status· Identify lifetime trauma history and duration of exposure· Record current and past medications (including over-the-counter drugs and herbals) and psychosocial
treatment· Consider, with patient consent, obtaining an additional history from family, significant other, or both
· Perform mental status exam
· Consider, in cases of diagnostic uncertainty, use of validated structured clinical interviews for PTSD
(i.e., CAPS-5, PSSI) (see Recommendation 2)
Abbreviations: CAPS-5: Clinician-Administered Posttraumatic Stress Disorder Scale for Diagnostic and Statistical
Manual of Mental Disorders, Fifth Edition, Text Revision; PSSI: PTSD Symptom Scale - Interview Version

Sidebar 7: DSM-5-TR Diagnostic Criteria for PTSD(8)Criterion A. Exposure to actual or threatened death, serious injury, or sexual violence in one (ormore) of the following ways:
1. Directly experiencing the traumatic event(s).
2. Witnessing, in person, the event(s) as it occurred to others.
3. Learning that the traumatic event(s) occurred to a close family member or close friend. In cases ofactual or threatened death of a family member or friend, the event(s) must have been violent or
accidental.
4. Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first
responders collecting human remains, police officers repeatedly exposed to details of child abuse).
Note: Criterion A4 does not apply to exposure through electronic media, television, movies, or pictures
unless this exposure is work related.

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VA/DoD Clinical Practice Guideline for Management of PTSD– Provider Summary

Sidebar 7: DSM-5-TR Diagnostic Criteria for PTSD(8)Criterion B. Presence of one (or more) of the following intrusion symptoms associated with thetraumatic event(s), beginning after the traumatic event(s) occurred:
1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s).
2. Recurrent distressing dreams in which the content and/or affect of the dream are related to thetraumatic event(s).
3. Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic
event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme
expression being a complete loss of awareness of present surroundings)
4. Intense or prolonged psychological distress at exposure to internal or external cues that symbolizeor resemble an aspect of the traumatic event(s).
5. Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of
the traumatic event(s).
Criterion C. Persistent avoidance of stimuli associated with the traumatic event(s), beginning after
the traumatic event(s) occurred, as evidenced by one or both of the following:
1. Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely
associated with the traumatic event(s).
2. Avoidance or efforts to avoid external reminders (people, places, conversations, activities, objects,
situations) that arouse distressing memories, thoughts, or feelings about or closely associated withthe traumatic event(s).
Criterion D. Negative alterations in cognitions and mood associated with the traumatic event(s),beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of
the following:
1. Inability to recall an important aspect of the traumatic event(s) (typically due to dissociative amnesia
and not to other factors such as head injury, alcohol, or drugs).
2. Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world(e.g., “I am bad.”, “No one can be trusted,”, “The world is completely dangerous,”, “My whole
nervous system is permanently ruined”).
3. Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) thatlead the individual to blame themself or others.
4. Persistent negative emotional state (e.g., fear, horror, anger, guilt, shame).
5. Markedly diminished interest or participation in significant activities.
6. Feeling of detachment or estrangement from others.
7. Persistent inability to experience positive emotions (e.g., inability to experience happiness,satisfaction, or loving feelings).
Criterion E. Marked alterations in arousal and reactivity associated with the traumatic event(s),beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of
the following:
1. Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or
physical aggression toward people or objects.
2. Reckless or self-destructive behavior.
3. Hypervigilance.
4. Exaggerated startle response.
5. Problems with concentration.
6. Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).
Criterion F. Duration of the disturbance (Criteria B, C, D, and E) is more than 1 month.

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Sidebar 7: DSM-5-TR Diagnostic Criteria for PTSD(8)Criterion G. The disturbance causes clinically significant distress or impairment in social,occupational, or other important areas of functioning.
Criterion H. The disturbance is not attributable to the physiological effects of a substance (e.g.,
medication, alcohol) or another medical condition.
Specify whether:
With dissociative symptoms: The individual’s symptoms meet the criteria for posttraumatic stressdisorder, and in addition, in response to the stressor, the individual experiences persistent or recurrent
symptoms of either of the following:
1. Depersonalization: Persistent or recurrent experiences of feeling detached from, and as if one
were an outside observer of, one’s mental processes or body (e.g., feeling as though one were in a
dream; feeling a sense of unreality of self or body or of time moving slowly).
2. Derealization: Persistent or recurrent experiences of unreality of surroundings (e.g., the world
around the individual is experienced as unreal, dreamlike, distant, or distorted).
Note: To use this subtype, the dissociative symptoms must not be attributable to the physiological effects
of a substance (e.g., blackouts, behavior during alcohol intoxication) or another medical condition (e.g.,complex partial seizures).
Specify if:
With delayed expression: If the full diagnostic criteria are not met until at least 6 months after the event(although the onset and expression of some symptoms may be immediate).

Sidebar 8: Assessment of PTSD Symptoms· Assess PTSD symptoms using validated instruments, such as the PTSD Checklist for DSM-5 (PCL-5),
or a structured clinician-administered interview (e.g., CAPS-5) (see Recommendation 3).
Abbreviations: CAPS-5: Clinician-Administered PTSD Scale for DSM-5; DSM-5: Diagnostic and Statistical Manual of
Mental Disorders, Fifth Edition; PCL-5: PTSD Checklist for DSM-5; PTSD: posttraumatic stress disorder

Sidebar 9: Treatment Selection
1. Initiate recommended individual, manualized psychotherapy (see Recommendation 8) according topatient preference.
2. If individual psychotherapy is unavailable or not preferred, initiate recommended pharmacotherapy(see Recommendation 15).
3. If options 1 and 2 are infeasible or are not preferred, offer suggested psychotherapy (seeRecommendation 9) or suggested CIH (see Recommendation 26).
4. If options 1, 2, and 3 are infeasible or are not preferred, consider other psychotherapies (seeRecommendation 10, Recommendation 12, and Recommendation 14), other pharmacotherapy (seeRecommendation 16), complementary, integrative, or alternative approaches (see Recommendation
27 and Recommendation 28) based on availability, patient preference, and review of current evidence.
5. If none of the options above are acceptable to the patient, consider treating other disorders, issues, orboth and reevaluating for PTSD treatment later.
Abbreviations: CIH: complementary and integrative health; PTSD: posttraumatic stress disorder

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Sidebar 10: Additional Treatment and Support Needs· Consider treatment for comorbidities and other identified problems (see Recommendation 34 as well asother relevant VA/DoD CPGs*).
· Consider symptom-specific management (e.g., sleep, pain).
· Facilitate social support.
· Address Whole Health by offering CIH, alternative approaches, health and wellbeing coaching,recreation therapy, etc.
*VA/DoD CPGs can be found at the following link: https://www.healthquality.va.gov/index.asp. Relevant VA/DoD CPGs
to consult might include CPGs for the Management of Major Depressive Disorder, Substance Use Disorder, Bipolar
Disorder, Suicide, Chronic Multisymptomatic Illness, Concussion-Mild Traumatic Brain Injury, and others.
Abbreviations: CIH: complementary and integrative healthSidebar 11: Clinically Meaningful Response Time· Psychotherapies require an adequate dosage to be fully effective in reducing PTSD symptoms; someeffects might also not become apparent until some period has elapsed after treatment is initiated. For
the indicated psychotherapies for PTSD (see Recommendation 8), it is generally accepted that initial
treatment effects will be noticeable after 4–8 sessions typically delivered over 8–12 weeks.
Psychotherapies might have an attenuated effect if delivered less than weekly.
· The pharmacological management of PTSD requires the SSRI (e.g., sertraline) or SNRI
(e.g., venlafaxine) be given at an appropriate dosage for an adequate time to allow for the fulltherapeutic effects before moving to alternative or augmentative treatment options. These medications
should be initiated at the recommended starting dose and titrated based on clinical response andtolerability (see Appendix B in the full VA/DoD PTSD CPG). The duration of the trial should be
8-12 weeks.
Abbreviations: PTSD: posttraumatic stress disorder; SNRI: serotonin-norepinephrine reuptake inhibitor; SSRI: selective
serotonin reuptake inhibitor

Sidebar 12: Maintenance Plan
· Terminate PTSD treatment or taper based on clinician judgment and patient preference, normalize
fluctuations in symptoms, discuss self-monitoring for symptoms that warrant future attention, andprovide resources for seeking care in the future.
· Before termination of psychopharmacology, discuss the risks and benefits of discontinuing medication,
including possible side effects and return of symptoms. Make a schedule to taper based on patient
preference with a discussion of the length of time required and consideration of anticipated life eventsand stressors. Discuss the plan for monitoring during and post taper, including steps needed toreinitiate pharmacology.
· Should the patient wish to continue pharmacotherapy, investigate, and discuss continuing medications
with behavioral health or primary care.
· Refer the patient for treatment of other disorders or functional issues (e.g., relationship distress).
· If desired, facilitate referral to health and wellbeing programs as a part of a Whole Health approach tocare.
Abbreviations: PTSD: posttraumatic stress disorder

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VA/DoD Clinical Practice Guideline for Management of PTSD– Provider Summary

Pharmacotherapy Dosing Table
Table 3: Pharmacotherapy Dosing Table
Therapeutic
Category

Initial Dose

AntidepressantsMonotherapy· Paroxetine

IR: 10–20 mg daily
CR: 12.5 mg daily· Sertraline

25–50 mg daily· Venlafaxine

IR: 25 mg 2 or 3 times aday
XR: 37.5 mg daily

Dose Range· All antidepressants have a Black Box warning for increased risk ofsuicidality in children and young adults (≤24 years) in short-term
studiesof MDD and other psychiatric disorders.
20–50 mg daily· Avoid abrupt discontinuation; withdrawal symptoms can occur with
12.5–50 mg
sudden discontinuation of SSRIs and SNRIs, paroxetine and
50–200 mg daily
venlafaxine in particular.
·
Paroxetineand sertraline have FDA indications for treating PTSD.
75–375 mg in 2–3 divided· Common adverse effects of the SSRIs and SNRIs include nausea,
doses
headache, diarrhea, nervousness, sexual dysfunction, dizziness.
75–300 mg once daily· Hyponatremia or SIADH can occur; risk is elevated in patients >65
years.
· Venlafaxine can elevate blood pressure; caution is advised withpatients with hypertension.
· Serotonin syndrome can occur, especially with concomitant
medications that affect serotonin.

Other Agents· Prazosin#

1 mg at bedtime; titrate toclinical response.

Clinical Considerations: Comorbidities and Safety

3–20 mg at bedtime· Prazosin might cause syncope with a sudden loss of consciousness.
Syncopal episodes usually occur within 30 to 90 minutes of the initial
dose.
· Addition of a diuretic, other antihypertensive agents, or a PDE5
inhibitor might cause an additive hypotensive effect.

Abbreviations: CR: controlled release; FDA: Food and Drug Administration; IR: immediate release; MDD: major depressive disorder; mg: milligram;
PDE5: phosphodiesterase-5; PTSD: posttraumatic stress disorder; SIADH: syndrome of inappropriate antidiuretic hormone; SNRI: serotonin/norepinephrine reuptake
inhibitor; SSRI: selective serotonin reuptake inhibitor; XR: extended release# for the treatment of nightmares associated with PTSD

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VA/DoD Clinical Practice Guideline for Management of PTSD – Provider Summary

Methods
The methodology used in developing this CPG follows the Guideline for Guidelines, aninternal document of the VA/DoD EBPWG updated in January 2019 that outlines
procedures for developing and submitting VA/DoD CPGs.(1) The Guideline for Guidelines
is available at http://www.healthquality.va.gov/policy/index.asp. This CPG also aligns with
the National Academy of Medicine’s (NAM) principles of trustworthy CPGs (e.g.,
explanation of evidence quality and strength, management of potential conflicts of interest[COI], interdisciplinary stakeholder involvement, use of SR and external review).(9)Appendix A in the full VA/DoD PTSD CPG provides a detailed description of the CPG
development methodology.
The Work Group used the Grading of Recommendations Assessment, Development and
Evaluation (GRADE) approach to craft each recommendation and determine its strength.
Per GRADE approach, recommendations must be evidence-based and cannot be madebased on expert opinion alone. The GRADE approach uses the following four domains to
inform the strength of each recommendation: confidence in the quality of the evidence,balance of desirable and undesirable outcomes, patient values and preferences, otherconsiderations as appropriate (e.g., resource use, equity) (see Grading
Recommendations in the full VA/DoD PTSD CPG).(10)Using these four domains, the Work Group determined the relative strength of each
recommendation (Strong or Weak). The strength of a recommendation is defined as theextent to which one can be confident that the desirable effects of an intervention outweighits undesirable effects and is based on the framework above, which incorporates the fourdomains.(11) A Strong recommendation generally indicates High or Moderate confidence
in the quality of the available evidence, a clear difference in magnitude between thebenefits and harms of an intervention, similar patient values and preferences, andunderstood influence of other implications (e.g., resource use, feasibility).
In some instances, insufficient evidence exists on which to base a recommendation for oragainst a particular therapy, preventive measure, or other intervention. For example, thesystematic evidence review might have found little or no relevant evidence, inconclusive
evidence, or conflicting evidence for the intervention. The manner in which this finding is
expressed in the CPG might vary. In such instances, the Work Group might include
among its set of recommendations a statement of insufficient evidence for an intervention
that might be in common practice although it is unsupported by clinical evidence andparticularly if other risks of continuing its use might exist (e.g., high opportunity cost,misallocation of resources). In other cases, the Work Group might decide to exclude thistype of statement about an intervention. For example, the Work Group might remain silent
where an absence of evidence occurs for a rarely used intervention. In other cases, anintervention might have a favorable balance of benefits and harms but might be astandard of care for which no recent evidence has been generated.

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Using these elements, the Work Group determines the strength and direction of each
recommendation and formulates the recommendation with the general corresponding text
as shown in Table 4.
Table 4. Strength and Direction of Recommendations and General Corresponding Text
Recommendation Strengthand Direction

General Corresponding Text

Strong for

We recommend . . .

Weak forWe suggest . . .

Neither for nor against

There is insufficient evidence to recommend for or against . . .

Weak against

We suggest against . . .

Strong against

We recommend against . . .

The GRADE of each recommendation made in the 2023 CPG can be found in the section
on Recommendations. Additional information regarding the use of the GRADE system
can be found in Appendix A in the full VA/DoD PTSD CPG.

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References
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U.S. Department of Veterans Affairs/Department of Defense Health Executive Committee(HEC). Evidence Based Practice Work Group Charter [updated January 9, 2017]. Availablefrom:www.healthquality.va.gov/documents/EvidenceBasedPracticeWGCharter123020161.pdf.

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Guyatt GH, Oxman AD, Kunz R, Atkins D, Brozek J, Vist G, et al. GRADE guidelines: 2.
Framing the question and deciding on important outcomes. Journal of clinical epidemiology.
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Robinson JH, Callister LC, Berry JA, Dearing KA. Patient-centered care and adherence:
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Stewart M, Brown JB, Donner A, McWhinney IR, Oates J, Weston WW, et al. The impact ofpatient-centered care on outcomes. J Fam Pract. 2000;49(9):796-804. Epub 2000/10/14.
PubMed PMID: 11032203.

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National Learning Consortium. Shared Decision Making 2013. Available from:https://www.healthit.gov/sites/default/files/nlc_shared_decision_making_fact_sheet.pdf.

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Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21stCentury. Washington DC: National Academies Press, 2001.

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Society for Medical Decision Making Committee on Standardization of Clinical Algorithms.
Proposal for clinical algorithm standards. Med Decis Making. 1992;12(2):149-54.
Epub 1992/04/01. PubMed PMID: 1573982.

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Association AP. Diagnostic and statistical manual of mental disorders, Text Revision (DSM5-TR®). Fifth, Text Revision ed. Arlington, VA: American Psychiatric Association; 2022.

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Ransohoff DF, Pignone M, Sox HC. How to decide whether a clinical practice guideline istrustworthy. Jama. 2013;309(2):139-40. Epub 2013/01/10. doi: 10.1001/jama.2012.156703.
PubMed PMID: 23299601.

10.

Andrews JC, Schunemann HJ, Oxman AD, Pottie K, Meerpohl JJ, Coello PA, et al. GRADE
guidelines: 15. Going from evidence to recommendation-determinants of arecommendation's direction and strength. Journal of clinical epidemiology. 2013;66(7):72635. Epub 2013/04/11. doi: 10.1016/j.jclinepi.2013.02.003. PubMed PMID: 23570745.

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Andrews J, Guyatt G, Oxman AD, Alderson P, Dahm P, Falck-Ytter Y, et al. GRADE
guidelines: 14. Going from evidence to recommendations: the significance and presentationof recommendations. Journal of clinical epidemiology. 2013;66(7):719-25. Epub 2013/01/15.
doi: 10.1016/j.jclinepi.2012.03.013. PubMed PMID: 23312392.

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Access to the full guideline and additional resources is available at:https://www.healthquality.va.gov/.