Understanding

Posttraumatic Stress
Disorder:
From Assessment to Treatment

2nd Edition

By
Michelle Pardee, DNP, FNP-BC

Upon successful completion of this course, continuing education hours will be awarded as follows:
Nurses: 3 Contact Hours*
*Western Schools is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.
 P.O. Box 1930
Brockton, MA
02303 800-438-8888
ABOUT THE AUTHOR
Michelle Pardee, DNP, FNP-BC, is a family nurse practitioner (FNP) and clinical assistant professor
at the University of Michigan School of Nursing. Dr. Pardee is the program lead for the FNP program
and coordinator of academic programs in the Department of Health Behavior & Biological Sciences.
She received her doctor of nursing practice degree from Wayne State University, where her doctoral
project was a policy analysis of Michigan’s maternal-infant health program. Dr. Pardee has more than
20 years of clinical experience as an FNP in adolescent health, providing care to underserved and at-risk
youth, including runaway and homeless persons. In addition to her academic position, she currently pro-
vides health care at a grant-funded, school-linked health center. Dr. Pardee is a member of the Complex
ACEs, Complex Aid (CASCAID) Nursing Study Group at the University of Michigan School of
Nursing. Her work includes conducting research on adverse childhood experiences, developing assess-
ments and interventions for youth with a high level of adverse childhood experiences, and increasing
trauma-informed education across nursing curriculums.
Michelle Pardee has disclosed that she has no significant financial or other conflicts of interest per-
taining to this course book.
ABOUT THE PEER REVIEWER
David C. Rozek, PhD, is a clinical psychologist and holds a primary appointment at the University of
Utah in the Department of Psychiatry, with a secondary appointment at the National Center for Veterans
Studies. Dr. Rozek received his PhD from the University of Notre Dame and completed his residency at
the Orlando Veterans Affairs Medical Center. His research and clinical expertise are in understanding and
treating stress-related disorders, including posttraumatic stress disorder, depression, and suicide. Dr. Rozek
regularly provides training to clinicians and medical professionals on cognitive- and behavioral-based
treatments for these disorders and is an active researcher focusing on how to best improve clinical care.
David C. Rozek has disclosed that he has no significant financial or other conflicts of interest per-
taining to this course book.
Nurse Planner: Patricia Hojnowski-Diaz, MS, MBA, RN
The planner who worked on this continuing education activity has disclosed that she has no significant financial
or other conflicts of interest pertaining to this course book.
Copy Editor: Graphic World, Inc.
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Western Schools’ courses and course materials are not meant to act as a substitute for seeking professional advice or
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Western Schools’ course materials are intended solely for your use and not for the purpose of providing advice or
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ISBN: 978-1-68041-472-1
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ii
 COURSE INSTRUCTIONS
IMPORTANT: Read these instructions BEFORE proceeding!
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3) Complete the course evaluation

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iii
 WESTERN SCHOOLS
COURSE EVALUATION
UNDERSTANDING POSTTRAUMATIC STRESS DISORDER:
FROM ASSESSMENT TO TREATMENT
INSTRUCTIONS: Using the scale below, please respond to the following evaluation statements. All
responses should be recorded in the right-hand column of the FasTrax answer sheet, in the section
marked “Evaluation.” Be sure to fill in each corresponding answer circle completely using blue or black
ink. Leave any remaining answer circles blank.
A B C D

Agree Agree Disagree Disagree

Strongly Somewhat Somewhat Strongly

OUTCOMES: After completing this course, I am able to:

1. Discuss the history, incidence, etiology, and risk factors for PTSD.
2. Identify diagnostic criteria across all age groups for PTSD.
3. Discuss screening and assessment for PTSD.
4. Identify the major clinical signs and symptoms of PTSD, including differential diagnosis related
to PTSD.
5. Discuss special considerations for specific population groups when assessing and diagnosing PTSD.
6. Describe therapeutic approaches for treating and managing PTSD.

COURSE CONTENT
7. The course content was presented in a well-organized and clearly written manner.
8. The course content was presented in a fair, unbiased, and balanced manner.
9. The course content presented current developments in the field.
10. The course was relevant to my professional practice or interests.
11. The final examination was at an appropriate level for the content of the course.
12. The course expanded my knowledge and enhanced my skills related to the subject matter.
13. I intend to apply the knowledge and skills I’ve learned to my practice.
A. Yes B. Unsure C. No D. Not Applicable
CUSTOMER SERVICE
The following section addresses your experience in interacting with Western Schools. Use the scale
below to respond to the statements in this section.
A. Yes B. No C. Not Applicable
14. Western Schools staff was responsive to my request for disability accommodations.
15. The Western Schools website was informative and easy to navigate.
16. The process of ordering was easy and efficient.
17. Western Schools staff was knowledgeable and helpful in addressing my questions or problems.

continued on next page

v
 Course Evaluation—
vi Understanding Posttraumatic Stress Disorder: From Assessment to Treatment

ATTESTATION
18. I certify that I have read the course materials and personally completed the final examination based
on the material presented. Mark “A” for Agree and “B” for Disagree.

COURSE RATING
19. My overall rating for this course is
A. Poor B. Below Average C. Average D. Good E. Excellent

You may be contacted within 3 to 6 months of completing this course to participate in a brief
survey to evaluate the impact of this course on your clinical practice and patient/client outcomes.
Note: To provide additional feedback regarding this course and Western Schools services, or to suggest new course topics, use the
space provided on the Important Information form found on the back of the FasTrax instruction sheet included with your course.
 CONTENTS
Course Evaluation.....................................................................................................................................v
Pretest.......................................................................................................................................................ix
Introduction.............................................................................................................................................xi
Course Objectives.........................................................................................................................xi
Learning Outcome.........................................................................................................................xi
Overview.......................................................................................................................................xi
Understanding Posttraumatic Stress Disorder: From Assessment to Treatment..............................1
History............................................................................................................................................1
Incidence........................................................................................................................................2
Etiology..........................................................................................................................................2
Risk and Resiliency Factors...........................................................................................................3
Diagnosis of PTSD.........................................................................................................................4
Diagnostic Criteria...................................................................................................................4
Cohort 1: Adults, Adolescents, and Children Over Age 6.................................................4
Cohort 2: Children Age 6 and Younger.............................................................................5
Initial Screening and Assessment.............................................................................................6
Adults.................................................................................................................................7
Children and Adolescents...................................................................................................7
Clinical Signs and Symptoms..................................................................................................9
Differential Diagnosis............................................................................................................10
Acute Stress Disorder.......................................................................................................10
Adjustment Disorder........................................................................................................10
Anxiety Disorders............................................................................................................10
Depression........................................................................................................................10
Psychotic Disorders..........................................................................................................10
Special Considerations.................................................................................................................11
Pregnant and Postpartum Patients..........................................................................................11
Children and Adolescent Patients..........................................................................................11
Older Adult Patients...............................................................................................................12
Patients Who Are Veterans....................................................................................................12
Lesbian, Gay, Bisexual, and Transgender Patients................................................................13
Treatment of PTSD......................................................................................................................13
Therapeutic Goals..................................................................................................................14
Therapies................................................................................................................................14
vii
 Contents—
viii Understanding Posttraumatic Stress Disorder: From Assessment to Treatment
Cognitive-Behavioral Therapy.........................................................................................14
Exposure-Based Interventions..........................................................................................16
Cognitive Interventions....................................................................................................16
Psychoeducation...............................................................................................................17
Symptom Management....................................................................................................17
Psychopharmacology.......................................................................................................18
New Research and Interventions..................................................................................................19
Case Study 1.................................................................................................................................21
Questions................................................................................................................................21
Responses...............................................................................................................................21
Case Study 2.................................................................................................................................22
Questions................................................................................................................................22
Responses...............................................................................................................................22
Case Study 3.................................................................................................................................23
Questions................................................................................................................................23
Responses...............................................................................................................................23
Summary......................................................................................................................................24
Exam Questions......................................................................................................................................25
Appendix.................................................................................................................................................29
Resources................................................................................................................................................31
References...............................................................................................................................................33
 PRETEST
1. Begin this course by taking the pretest. Circle the answers to the questions on this page, or write the
answers on a separate sheet of paper. Do not log answers to the pretest questions on the FasTrax test
sheet included with the course.
2. Compare your answers with the answers in the PRETEST KEY located at the end of the pretest. The
pretest key indicates the page where the content of that question is discussed. Make note of the ques-
tions you missed, so that you can focus on those areas as you complete the course.
3. Read the entire course and complete the exam questions at the end of the course. Answers to the
exam questions should be logged on the FasTrax test sheet included with the course.
Note: Choose the one option that BEST answers each question.

1. During World War I, veterans with 3. Which of the following is an accurate

symptoms of posttraumatic stress disorder statement about the use of assessment tools
(PTSD) were said to be experiencing in identifying PTSD?
a. hysteria. a. No assessment tools are currently
b. madness. effective in identifying PTSD.
c. shell shock. b. Multiple assessment tools can be used
d. insanity. in identifying PTSD.
c. PTSD can be identified only through
2. An example of a negative change in structured diagnostic interviews.
cognition or mood following a traumatic d. PTSD can be identified only through a
event that meets the diagnostic criteria review of the client’s medical records.
for PTSD is
a. insomnia. 4. Children with PTSD most likely
demonstrate play behaviors that are
b. hypervigilance.
c. forgetfulness about the event. a. repetitive and agitated.
d. nightmares about the event. b. structured and cohesive.
c. organized and rigid.
d. angry and violent.

continued on next page

ix
 Pretest—
x Understanding Posttraumatic Stress Disorder: From Assessment to Treatment
5. Assessing and diagnosing PTSD in the
veteran population is challenging because
a. no assessment tools have been
developed specifically for use with
veterans.
b. veterans are always reluctant to disclose
their military history.
c. PTSD in this population has not been
extensively researched.
d. PTSD often overlaps with other
disorders among veterans.

6. Exposure therapy techniques for the

treatment of PTSD
a. have received empirical support for
their effectiveness.
b. have been determined to be ineffective.
c. are effective only when used with adults.
d. are effective only when also used with
psychopharmacology.

PRETEST KEY
1. C page 1
2. C page 5
3. B page 6-7
4. A page 9
5. D page 12
6. A page 15
 INTRODUCTION
COURSE OBJECTIVES
After completing this course, the learner will be able to:
1. Discuss the history, incidence, etiology, and risk factors for PTSD.
2. Identify diagnostic criteria across all age groups for PTSD.
3. Discuss screening and assessment for PTSD.
4. Identify the major clinical signs and symptoms of PTSD, including differential diagnosis
related to PTSD.
5. Discuss special considerations for specific population groups when assessing and diag-
nosing PTSD.
6. Describe therapeutic approaches for treating and managing PTSD.

LEARNING OUTCOME

A fter completing this course, the learner will be able to identify posttraumatic stress disorder
(PTSD) criteria, including major clinical signs and symptoms, and appropriate assessment and
therapeutic options for treatment.

OVERVIEW

P osttraumatic stress disorder (PTSD) is a complex syndrome that may occur after exposure to one or
more traumatic events. PTSD involves a characteristic set of symptoms that includes re- experiencing
the traumatic event, avoiding stimuli associated with the traumatic event, having negative changes in
mood or cognitions associated with or worsening after the traumatic event, and experienc- ing increased
reactivity and arousal. According to the fifth edition of the Diagnostic and Statistical Manual of Mental
Disorders (DSM-5), these symptoms are associated with clinically significant dis- tress and impairment,
including reduced social functioning and job performance (American Psychiatric Association [APA],
2013). Moreover, individuals experiencing PTSD may also have other psychiatric disorders that are
frequently comorbid with PTSD, such as depression, anxiety, obsessive-compulsive disorder and related
disorders, and substance use disorders, as well as somatic complaints and physical
illnesses (Dayan, Rauchs, & Guillery-Girard, 2017; Wynn & Benedek, 2017).
Individuals of any age, including children, may develop PTSD after experiencing a traumatic event
(APA, 2013; National Institute of Mental Health [NIMH], 2016). Moreover, many types of events may
qualify as traumatic stressors, including combat experiences, sexual assault, accidents, natural disasters,
xi
 Introduction—
xii Understanding Posttraumatic Stress Disorder: From Assessment to Treatment
and violent crime. An individual may develop PTSD after personally experiencing or witnessing such
events, learning that traumatic events were experienced by a close friend or family member, or after
having repeated and extreme exposure to details of traumatic events, such as exposure experienced by
first responders or police officers (APA, 2013; NIMH, 2016).
Most individuals exposed to traumatic stressors do not develop PTSD. The National Center for
PTSD reports that about 8% of the population will have PTSD at some point in their lives, with about
8 million adults experiencing it during any given year. In general, women experience PTSD at a higher
percentage than men (10% of women vs. 4% of men). Of the 15% to 43% of children and teens who
have had a trauma, 3% to 15% of girls and 1% to 6% of boys develop PTSD (U.S. Department of
Veterans Affairs, 2017a). With the high prevalence of trauma exposure within the United States, nurses
are providing care to many trauma-exposed patients who are at risk of developing PTSD, and nurses
may not have the comfort level or skills needed to assess and intervene appropriately. It is essential for
registered nurses, advanced practice registered nurses, and certified nurse specialists to routinely assess
for the presence of traumatic experiences, as well as possible PTSD symptoms, in all encounters with
patients and families so that interventions and referrals to treatment can be provided.
This course provides an overview of PTSD for nurses working in a variety of roles and settings. This
course addresses basic information regarding PTSD, including DSM-5 diagnostic criteria, etiology, inci-
dence, risk factors, interventions, and treatment methods.
 UNDERSTANDI
NGPOSTTRAUM
ATIC
S T R E S SD I S O R D E R :
FROM ASSESSMENT
T O TREATMEN T
HISTORY that many kinds of experiences could
overwhelm the psyche. He

A
lthough the term posttraumatic stress dis-
order (PTSD) was not coined until 1980, 1
descriptions of similar posttraumatic stress reac-
tions and such behaviors as nightmares, shaking,
persistent fear, and phobias as aftereffects of
traumatic events have been noted for centuries.
Civil War soldiers with such behaviors were said
to have “soldier’s heart.” In World War I, the
condition was called “shell shock” (Friedman,
Resick, & Keane, 2014; Weisaeth, 2014).
Although the descriptions of PTSD and its status
as a psychiatric disorder have changed over the
years, its inclusion in the 1980 publication of
the Diagnostic and Statistical Manual of Mental
Disorders (DSM-III) resulted in a burgeoning of
basic and clinical PTSD research over the next
three decades.
In 1889, Pierre Janet prepared meticulous
case histories of people who had been trau-
matized (Weisaeth, 2014). He hypothesized a
biologically based trauma response resulting in
a fragmentation of mental cohesion, causing
bio- logical, behavioral, cognitive, and
emotional res- idues of past experiences to
continue to govern current behavior. Janet found
was one of the first to suggest that when violent
emotions impair the capacity to think, feel, and act
in a purposeful, unified way, the situation must be
reflected in biology (Weisaeth, 2014).
In the 1900s, clinicians such as Sigmund Freud
began to recognize that traumatic events could
precipitate the development of psycho- logical
problems, collectively called traumatic neuroses.
The events of World War I confirmed for Freud
that trauma can have profound effects, and he
noted individuals’ seeming preoccupa- tion with
the trauma as well as their efforts to avoid
traumatic memories (Weisaeth, 2014).
The traumatic experiences of World War II led
to “gross stress reaction” being included as a
diagnosis in the first edition of the Diagnostic and
Statistical Manual of Mental Disorders (DSM-I)
in 1952. The second edition, the DSM-II,
published in 1968, eliminated this diag- nosis;
however, the experience of Vietnam vet- erans led
to its restoration in the DSM-III in 1980 as a
specific type of anxiety disorder called
“posttraumatic stress disorder.” Revisions in the
DSM-IV (1994) and the DSM-IV-TR (2000)
updated the precipitating traumatic events to
include the diagnosis of a life-threatening illness
and the sudden, unexpected death of a loved one
or close friend, and outlined three symptom
2 Understanding Posttraumatic Stress Disorder: From Assessment to Treatment

clusters for a PTSD diagnosis (Friedman et al.,

higher rates of PTSD are experienced by veter-
2014). Additionally, a new diagnosis, acute
ans and those whose job exposes them to trau-
stress disorder, was added to the DSM-IV to
matic experiences, such as law enforcement
address clinical symptoms that may occur in the
officers, firefighters, and emergency medical
period between the traumatic event and 1 month
providers, with the highest rates experienced
following the event, after which time a
by “survivors of rape, military combat and cap-
diagnosis of PTSD may be given. With the
tivity, and ethnically or politically motivated
DSM-5, PTSD was moved out of the anxiety
internment and genocide.” Research has shown
disorders category into a new diagnostic
that patients who have a traumatic orthopedic
category of diagnoses titled Trauma- and
injury (Muscatelli et al., 2017) or an intensive-
Stressor-Related Disorders. This new category
care unit stay (Bienvenu et al., 2015; Parker et
was placed near the anxiety disorders section,
al., 2015) are at an increased risk of developing
between obsessive-compulsive disorder and
PTSD. Although women are slightly less likely
related disorders and the dissocia- tive disorders
than men to be exposed to traumatic events,
categories to “reflect the close relationship
more women than men are diagnosed with
between these diagnoses and dis- orders” (APA,
PTSD, and women are twice as likely as men
2013, p. 265). The trauma- and stressor-related
to develop PTSD (U.S. Department of Veterans
disorders category includes such disorders as
Affairs, 2017d). Overall population estimates
reactive attachment disorder, acute stress
of PTSD among children and adolescents have
disorder, and adjustment disorders
not been established, and they vary according to
– with the unifying feature among the disorders
the type of trauma studied (sexual abuse, natural
being the explicit requirement of exposure to a
disaster), population of focus (inner-city, clinic,
traumatic or stressful event as a diagnostic cri-
rural), gender, and age group (Briggs, Nooner,
terion. The DSM-5 further specified those
& Amaya-Jackson, 2014; U.S. Department of
events that are considered traumatic
Veterans Affairs, 2017a). Although most people
experiences and added a fourth symptom cluster
will recover from a traumatic event, it is impor-
to the diagnos- tic criteria (explained in greater
tant for nurses at all levels to be vigilant for
detail in the diagnosis of PTSD section later in
patients whose symptoms extend beyond the
the course). Furthermore, the DSM-5 lowered
3-month threshold for a diagnosis of PTSD.
the diagnos- tic thresholds for children and
adolescents and added separate criteria for
children age 6 years and younger. ETIOLOGY

INCIDENCE S everal theories have been suggested to

explain the etiological factors underlying
the development of PTSD after exposure to a
E pidemiological studies estimate the rate
of lifetime PTSD in the United States as
ranging between 7% and 12% of the popula-
traumatic stressor. These factors include bio-
logical, psychological, and genetic processes.
Multiple causal pathways (rather than a single
tion (APA, 2013; Norris & Slone, 2014). At
causal pathway) likely play a role in the devel-
any given time in the United States, this can
opment of PTSD.
equate to roughly 6 million active cases of
PTSD in need of treatment (Norris & Slone, Biological theories focus on the activities and
2014). According to the DSM-5 (APA, 2013, changes that occur in the brain when an individual
p. 276),
Understanding Posttraumatic Stress Disorder: From Assessment to Treatment
is exposed to a traumatic stressor. According
to the DSM-5 (APA, 2013), the traumatic event
must involve exposure to actual or threatened
death, serious injury, or sexual violence by
directly experiencing or witnessing the event,
learning that a trauma occurred to a close fam-
ily member or friend, or having repeated or
extreme exposure to aversive details of trau-
matic events. Major traumatic events can be
sex- ual or physical assault, combat, motor
vehicle accidents, natural disasters, or terrorism
(APA, 2013). In addition, children and
adolescents can be exposed to maltreatment,
medical trauma, and community and school
violence (Fairbank, Putnam, & Harris, 2014).
When faced with a traumatic event, the job
of the human brain is to ensure survival. During
an acute stressor, the prefrontal cortex activ-
ity decreases and the amygdala tells the body
to produce stress hormones, including cortisol
and adrenaline, which leads to the physiologic
responses known as “fight or flight” and “freeze
or faint” (Van der Kolk, 2014). Once the trauma
is past, the prefrontal cortex recognizes there is
no longer a threat, and the body and brain return
to normal (unless recovery is blocked), the amyg-
dala remains turned on, and the body continues
to be alert for danger (Smith, Doran, Sippel, &
Harpaz-Rotem, 2017; Van der Kolk, 2014).
Among the psychological theories put for-
ward to explain the development of PTSD are
conditioning theories that focus on the develop-
ment of fear and anxiety. These theories posit
that fear is acquired through classical condi-
tioning, whereas avoidance is acquired through
operant conditioning. Emotional processing
theory attempts to explain PTSD based on the
presence of pathological emotion structures and
posits that successful treatment modifies the
pathological representation of the emo- tional
response. Another psychological expla- nation,
schema theory, hypothesizes that PTSD
3
develops because the traumatic event violates
an individual’s pre-existing assumptions about
the world and that processing traumatic events
requires modification of those assumptions.
Cognitive models of PTSD focus on traumatic
memories as well as negative appraisals of the
trauma that are processed as a constant threat
(Gillihan, Cahill, & Foa, 2014).
Research on the influence of genetic factors
indicates that genetics may indeed play a role in
the development of PTSD. Family studies indi-
cate an increased risk of PTSD in those whose
family members have experienced the disorder,
whereas studies of twins have demonstrated that
PTSD is heritable and that genetic influences
explain vulnerability to PTSD. Genetic research
continues to try to discover specific gene variants
and biomarkers that will identify people at high
risk of developing PTSD, which can aid in devel-
opment of interventions (Koenen et al., 2014).
RISK AND RESILIENCY
FACTORS
A s noted, not everyone exposed to a severe
trauma develops PTSD. As a result, under-
standing the risk and resiliency factors for
PTSD is highly warranted. Risk factors can be
categorized as pretraumatic, peritraumatic, or
posttraumatic. Pretraumatic variables include
female gender, younger age, pre-existing mental
illness, lower socioeconomic and educational
status, and family dysfunction (APA, 2013;
Friedman et al., 2014; Lancaster, Teeters, Gros,
& Back, 2016).
Research regarding peritraumatic variables
looks at the nature of the trauma, indicating
that the severity or magnitude of the trauma
influences development of PTSD. These vari-
ables include perceived life threat and personal
injury, especially interpersonal violence (such
as domestic or sexual assault). Intense negative
4 Understanding Posttraumatic Stress Disorder: From Assessment to Treatment
emotions, such as fear, shame, and guilt both
during and after the traumatic event, are also
risk factors. Dissociation, meaning mental and/
or emotional detachment during or after the
traumatic event, has also been identified as a
risk factor (APA, 2013; Lancaster et al., 2016).
Two major posttraumatic variables are a lack
of social support and exposure to additional life
stressors, including financial and trauma-related
losses, which can increase the likelihood of PTSD
(APA, 2013; Lancaster et al., 2016; Vogt, King,
& King, 2014). Individuals with inappropriate
coping strategies and who develop an acute stress
disorder are also at higher risk of developing
PTSD.
Although the preceding risk factors are
associated with increased potential for PTSD
development, other factors may be protective,
indicating increased resiliency in the face of
trauma exposure. According to the Merriam-
Webster dictionary, resilience is “an ability
to recover from or adjust easily to misfortune
or change” (Resilience, n.d.). This ability to
recover or adjust is influenced by many factors,
such as how we are raised, including our rela-
tionship to our parent/caregiver; how our brain
regulates stress, attention, learning, and mem-
ory; and having positive emotions (Southwick,
Douglas-Palumberi, & Pietrzak, 2014). Social
support has been shown to be a protective factor
in protecting individuals from developing PTSD
(Friedman et al., 2014; Southwick et al., 2014).
Social support is associated with self-confi-
dence, the use of effective coping strategies, and
regulating stress (Southwick et al., 2014), which
in turn can increase resiliency.
The risk and resiliency factors mentioned in
the preceding section have been associated with
the trajectory of PTSD. However, much more
needs to be done to comprehend the complex
interactions between them, including cultural
differences, to facilitate better understanding
and development of treatments for PTSD.
DIAGNOSIS OF PTSD
Diagnostic Criteria
PTSD is one of the trauma- and stressor-
related disorders defined in the DSM-5. PTSD
presents with four symptom clusters: re-
experiencing the event (intrusive symptoms),
avoidance of the event, negative cognitions and
mood following the event, and increased arousal
associated with the event. The DSM-5 has iden-
tified two broad age cohorts for this disorder:
the first group includes adults, adolescents, and
children over 6 years of age; the second group
includes children 6 years of age and younger.
Cohort 1: Adults, Adolescents, and
Children Over Age 6
Specifically, the DSM-5 diagnostic criteria
for PTSD in adults, adolescents, and children
over 6 years of age (APA, 2013) have seven
main characteristics:
1. Exposure to a traumatic event, with
actual or threatened death, serious
injury, or threat to physical integrity of
self or directly witnessing the event or
events happen to others. This includes
learning that the event has occurred to a
close family member or friend (in the event
of actual or threatened death, the event must
have been accidental or violent). It also
includes experi- encing extreme and
repeated exposure to the details or aftermath
of traumatic events, as in the case of first
responders.
2. Persistent re-experiencing of the event.
This may include one or more of the follow-
ing: a) involuntary intrusive and distressing
recollections of the event; b) recurring, dis-
tressing dreams related to the event; c) disso-
ciative experiences (e.g., flashbacks), which
Understanding Posttraumatic Stress Disorder: From Assessment to Treatment 5

is when an individual feels or acts as if the

6. Continuance of the symptoms for more
traumatic event(s) were recurring, or a com-
than 1 month. Typically, symptoms begin
plete loss of awareness of present surround-
to surface within the first 3 months of the
ings; d) psychological distress upon exposure
traumatic event.
to internal or external cues reminiscent of
the event; or e) physiological reactivity upon 7. Significant impairment of function in
exposure to internal or external cues reminis- social or occupational activities or other
cent of the event. activities.
3. Persistent avoidance of internal experi- Cohort 2: Children Age 6 and Younger
ences or external cues that remind the For children 6 years of age and younger, the
person of the event. To meet this diagnos- criteria vary slightly. Specifically, these criteria
tic criterion, the individual must avoid, or in the DSM-5 (APA, 2013) are:
make efforts to avoid, any event-associated
1. Exposure to actual or threatened death,
memories, thoughts, or feelings; or avoid,
serious injury, or sexual violence in one or
or make efforts to avoid, external cues –
more of the following ways: a) directly
such as certain activities, locations, objects,
expe- riencing the traumatic event; 2)
situations, or persons – associated with the
witnessing the event as it occurred to others,
event that might trigger remembrance of
especially if a primary caregiver; or 3)
the trauma. Doing both of these also would
learning that the traumatic event occurred to
meet this diagnostic criterion.
a parent or a caregiver.
4. Negative changes in cognitions and mood
2. Intrusion symptoms that begin after the
following and related to the traumatic
traumatic event, including a) recurrent,
event. Two or more of the following need to
involuntary, and intrusive distressing memo-
be present to meet this diagnostic criterion:
ries of the event; b) recurrent distressing
a) forgetfulness about the trauma (not related
dreams in which content or affect are related
to head injury, drug or alcohol use, or other
to the traumatic event; c) dissociative reac-
factors); b) persistent and exaggerated nega-
tions where the child feels or acts as if the
tivity about oneself, others, and the world; c)
traumatic event is recurring, which may be
persistent and distorted cognitions about the
re-enacted during play; d) intense or pro-
reason for the traumatic event or its conse-
longed psychological distress to exposure
quences, resulting in self-blame or blaming
of a cue that symbolizes or resembles some
others; d) loss of interest or withdrawal from
aspect of the trauma; and e) marked physi-
participation in activities that were previously
ological reactions to a reminder of the trau-
enjoyed; e) detachment from others; f) persis-
matic event.
tent negative emotions; and g) the inability to
feel positive emotions. 3. Avoidance of stimuli or negative altera-
tion in cognition and mood associated
5. Presence of symptoms of increased arousal
with the event that is present, beginning
not seen before the trauma. This must
after the event or worsening after the
include at least two of the following: insom-
event. This includes avoidance or effort to
nia, irritability or anger, increased vigilance,
avoid people and activities, conversations,
concentration difficulties, and an intensified
places, or physical reminders that arouse
startle response.
recollection of the event. It also includes
6 Understanding Posttraumatic Stress Disorder: From Assessment to Treatment
substantially increased frequency of nega-
tive emotional states, such as fear, guilt, or
shame; diminished interest or participation
in activities; socially withdrawn behavior;
and persistent reduction in expression of
positive emotions.
4. Alterations in arousal and reactivity asso-
ciated with the event, beginning or wors-
ening after the event occurred. Examples
include irritable behavior and angry out-
bursts typically expressed as verbal or phys-
ical aggression toward people or objects,
hypervigilance, exaggerated startle response,
problems with concentration, and sleep
disturbance.
5. Duration of the disturbance of more than
1 month.
6. A disturbance that causes clinically sig-
nificant distress or impairment in rela-
tionships with parents, siblings, peers, or
other caregivers or in school.
7. A disturbance that is not attributable to
physiological effects of a substance or
another medical condition.
Regardless of age, if an individual’s symp-
toms meet the criteria for PTSD, the DSM-5
specifies two subtypes: those with dissociative
symptoms or those with delayed expression.
Dissociative symptoms are depersonalization,
which is persistent or recurrent experiences of
feeling detached from self, or as if in a dream,
and derealization, which is persistent or recur-
rent experiences of unreality of surroundings.
Delayed expression is when full diagnostic cri-
teria are not met within 6 months after the trau-
matic event (although some symptoms may
be experienced and expressed sooner). Some
individuals with PTSD may primarily experi-
ence only one of the four symptom clusters:
re-experiencing the event, avoidance of the
event, negative cognitions and mood following
the event, or increased arousal associated with
the event, whereas other individuals with PTSD
might exhibit a mix of these symptoms. For
example, some individuals may primarily pres-
ent with fear-based re-experiencing of emo-
tional and behavioral symptoms; others may
present primarily with dysphoria, numbing, and
negative cognitions; and still others may display
increased arousal in which hypervigilance and
poor concentration may dominate. Additionally,
the predominance of certain symptoms may
vary over time (APA, 2013).
The World Health Organization (WHO)
International Classification of Diseases, 11th
version (ICD-11) has proposed a second PTSD
diagnosis – complex PTSD (CPTSD) – which
would be a distinct disorder and encompass
those individuals who have experienced child-
hood psychological trauma, or those multi-
ply traumatized in childhood and adulthood
(Karatzias et al., 2017). It includes the core
symptoms of PTSD and adds affective dysregu-
lation, negative self-concept, and disturbances
in relationships (Karatzias et al., 2017).
Initial Screening and Assessment
Nurses in every aspect of health care work
with and provide care for individuals across the
life span, families, and communities that have
experienced at least one traumatic event, if not
more. It is essential that nurses at all levels are
comfortable in assessing for trauma exposure
and PTSD symptoms and then referring, diag-
nosing, and treating patients (or all of these)
within the nurse’s scope of practice. The goals
of assessment vary depending on the required
out- come; assessment can include detecting
trauma exposure, evaluating DSM-5 criteria for
diag- nosis of PTSD, doing treatment
development and monitoring, or doing
symptom management (Lancaster et al., 2016;
Reardon, Brief, Miller, & Keane, 2014). The
desired outcomes will help guide the choice of
assessment method and
Understanding Posttraumatic Stress Disorder: From Assessment to Treatment
measures (Reardon et al., 2014). Assessment of
PTSD can include a wide range of approaches,
such as clinical interviews, self-report question-
naires, and review of medical records.
Adults
The first step in assessment is establish-
ing the history of a traumatic stressor or event
as described in the DSM-5 diagnostic criteria.
Actual or threatened death, serious injury, or
sexual violence are qualifying events. The
traumatic event must have involved actual or
threatened physical harm to one’s self or been
witnessed firsthand happening to another per-
son. Other qualifying experiences are learning
of the event happening to a close family mem-
ber or friend or having repeated and extreme
exposure to the details of such events, as in
the case of first responders (APA, 2013). The
trauma exposure can be a onetime event (e.g.,
a school or workplace shooting) or multiple
experiences of the same event (e.g., ongoing
child abuse) or different traumas (e.g., child
abuse, then sexual assault as an adult). Several
brief tools can be used in busy clinic settings to
screen for exposure to a traumatic event. These
questionnaires are the Trauma Assessment of
Adults; the Brief Trauma Questionnaire; the
Life Events Checklist; and the Trauma Life
Events Questionnaire (Lancaster et al., 2016;
Reardon et al., 2014). An assessment for
PTSD symptoms can occur simultaneously or
after the identification of a trauma exposure
to determine whether a more in-depth assess-
ment is necessary. Screening for symptoms can
be done with the Primary Care PTSD Screen,
the Posttraumatic Stress Disorder Checklist
for DSM-5 (PCL-5), the Trauma Screening
Questionnaire, and the Short Post-Traumatic
Stress Disorder Rating Interview (Lancaster et
al., 2016).
Once the initial screening is done and a
trauma exposure and PTSD symptoms exist,
7
more advanced assessment procedures should be
done to establish the diagnosis of PTSD. These
diagnostic assessments are clinician-administered
interviews that take much more time and should
be done by someone who has been trained in the
use of the tool and the process. The Clinician
Administered PTSD Scale is the gold standard
in PTSD assessment (Weathers et al., 2013a).
This structured interview tool can take up to
1 hour to complete and can be used to diagnose
PTSD and assess PTSD symptoms over the past
week or month and over a lifetime (Weathers
et al., 2013a). Three versions of the Clinician
Administered PTSD Scale correspond to differ-
ent periods: the past week, the past month, and
the worst month (lifetime). For diagnostic pur-
poses, PTSD status should be evaluated using
the past month version (for current PTSD) or
the worst-month version (for lifetime PTSD;
U.S. Department of Veterans Affairs, 2017b).
The Structured Clinical Interview of DSM-5
Disorders not only reliably diagnoses PTSD but
also assesses for comorbid psychiatric disorders
(Lancaster et al., 2016; Reardon et al., 2014).
Once the diagnosis of PTSD is established, fur-
ther assessment is done on symptom frequency
and severity so that treatment can be planned and
then monitored (Lancaster et al., 2016).
The assessment of PTSD symptom fre-
quency and severity can be accomplished by
clinician-directed interview using the Anxiety
Disorder Interview Schedule for DSM-5 or the
PTSD Symptom Scale Interview (Lancaster et
al., 2016; Reardon et al., 2014). Assessment of
symptoms can also be accomplished with self-
report questionnaires such as the PTSD
Checklist for DSM-5 (Weathers et al., 2013b)
or the Posttraumatic Stress Diagnostic Scale for
DSM-5 (Foa et al., 2015). The self-report ques-
tionnaires can be completed by anyone and do
not require special training.
8 Understanding Posttraumatic Stress Disorder: From Assessment to Treatment
Children and Adolescents
Assessing for trauma exposure and PTSD
symptoms for any age group can be intimidating,
but for many nurses it can be especially chal-
lenging when assessing a child or an adolescent.
Because of the high rates of trauma exposure
and the potential for development of PTSD, it
is critical for nurses to address this issue when
providing care for children and adolescents
to ameliorate the long-term effects of PTSD.
Developmentally, this task can be challenging,
because the child or adolescent may not yet
have the cognitive or language skills to identify
trauma and its symptoms (Briggs et al., 2014).
These challenges influence the choice of assess-
ment tools.
According to Briggs and colleagues (2014),
the following are things to consider when
assessing children and adolescents for PTSD:
1. Current age and developmental stage/age
when the trauma(s) occurred
2. Type, severity, and duration of the trauma(s)
3. Context of the trauma, especially as it
relates to the family and the home
environment
4. Parental support
5. Cultural norms of the child/adolescent and
family
6. Legal issues and involvement of child wel-
fare organizations
7. Additional risk factors such as socioeco-
nomic or educational level
8. Protective factors such as social support and
positive coping strategies
This information can provide direction to
assist the nurse in determining which assess-
ment tool is the most appropriate to assess
symptoms, reduce distress, and provide the best
information for diagnosis and treatment devel-
opment and monitoring (Briggs et al., 2014).
As with adult assessment tools, self-report
questionnaires and clinical interviews, in addi-
tion to caregiver reports, can be used with
children and adolescents. With the addition of
criteria for children 6 years and younger in the
DSM-5 (APA, 2013), tools will need to be
modi- fied and developed for this specific age
group to match their developmental stage. The
National Child Traumatic Stress Network
provides a database of reviews of tools that
measure chil- dren’s experiences of trauma,
their reactions to it, and other mental health and
trauma-related issues; it can be found at
http://www.nctsn.org/ resources/online-
research/measures-review. Although many
validated tools are available, only a few will be
highlighted here. The ini- tial step in
assessment is to screen for a history of trauma
exposure, whether a onetime, ongo- ing, or
multievent situation. This step can be done
using the clinician-administered Traumatic
Events Screening Inventory of Children, for
children age 4 years and up, which assesses for
a variety of potential traumatic events including
community violence, disasters, accidents, and
abuse (Briggs et al., 2014; U.S. Department of
Veterans Affairs, 2017a). A parent-report ver-
sion (TESI-PRR) is also available (U.S. Depart-
ment of Veterans Affairs, 2017a).
The Clinician-Administered PTSD Scale
for DSM-5 – Child/Adolescent Version
(CAPS-CA-5) is administered to assess trauma
exposure, PTSD criteria, and symptoms. It
includes age-appropriate items and picture-
response options that can be useful with
younger children (Pynoos et al., 2015). The
UCLS Child/ Adolescent PTSD Reaction Index
for DSM-5 is a semistructured interview that
assesses for trauma history and PTSD criteria. It
is intended as a brief screen and has a youth
version (ages 7 to 12 years), an adolescent
version (age 13 and older), and a parent version
(Briggs et al., 2014; U.S. Department of
Veterans Affairs,
Understanding Posttraumatic Stress Disorder: From Assessment to Treatment
2017a). Another tool that assesses PTSD crite-
ria and symptoms is the Child PTSD Symptom
Scale, developed by Foa, Johnson, Feeny, and
Treadwell (2001). The tool is a self-report
designed to be used with children aged 8 to 18
years, and it utilizes developmentally appropri-
ate language to ensure understanding of the
questions (Foa et al., 2001). One recent study
determined that the Child PTSD Symptom Scale
is good for assessing PTSD in children and ado-
lescents (Gillihan, Aderka, Conklin, Capaldi,
& Foa, 2013). Each of the tools described here
can be used to develop and monitor treatment,
including symptom severity. They should be
administered by someone familiar with PTSD
and who has had training with the specific tool.
Clinical Signs and Symptoms
According to the DSM-5 criteria (APA,
2013), four clusters of symptoms and corre-
sponding clinical signs are the hallmarks of
PTSD. These are 1) intrusion symptoms;
2) avoidance symptoms; 3) negative altered
cognition and mood, and 4) altered arousal and
reactivity (APA, 2013). These symptoms and
objective clinical signs can vary by person in
quantity, intensity, and amount of disruption
to life. Nurses may observe clinical signs and
symptoms in an individual before diagnosis of
PTSD or even identification of trauma history,
and these observations may be the first indica-
tion that an assessment is indicated. Intrusion
symptoms, characterized by repeatedly reliving
the event, can occur as flashbacks, in which
the individual believes that the event is actually
recurring. Anniversaries of the traumatic experi-
ence are often difficult for those with PTSD and
may trigger intrusive memories or flashbacks.
For example, a war veteran may experience
intrusive thoughts regarding combat upon hear-
ing a helicopter fly overhead. Intrusion can also
be experiencing bad dreams that contain content
that is related to the traumatic event. Avoidance
9
can present as persistent attempts to avoid peo-
ple, places, or activities that remind them of the
trauma event; or avoiding thoughts and feel-
ings regarding the event altogether. Although
such diligent avoidance may reduce intrusive
memories of the traumatic event, it can exacer-
bate symptoms in the negative cognitions and
mood cluster, leading to emotional numbing.
The person may lose interest in things they for-
merly enjoyed and feel detached (and different)
from others. Individuals with PTSD may state
that they can no longer feel or express emo-
tions, particularly in some of their closest rela-
tionships. These negative mood and cognition
symptoms often result in relationship problems
(APA, 2013; NIMH, 2016).
Hyperarousal symptoms are often evidenced
by hypervigilance, an increased awareness of
one’s surroundings and a significantly dimin-
ished ability to concentrate. Individuals may
report feeling as though they are “always look-
ing over their shoulder.” For example, a victim
of a mugging may report that she feels that she
is constantly on guard when walking in public.
Such hypervigilance is typically associated with
increases in heart rate, breathing, and muscle
tension and is often accompanied by an exag-
gerated startle response. Hyperarousal may also
be evidenced by increased irritability and anger
outbursts, even when provocation is not present.
Individuals with PTSD typically report sleep
disturbances, often because of intrusive night-
mares regarding the traumatic event.
Children typically present with different
symptoms than adults. They are most likely to
demonstrate repetitive play and behavior that
is disorganized and agitated. They have night-
mares but often cannot describe them. They also
develop somatic complaints, most commonly
headaches and stomachaches. They can show
irritability, difficulty concentrating, and sleep
disturbances (American Academy of Child &
10 Understanding Posttraumatic Stress Disorder: From Assessment to Treatment
Adolescent Psychiatry, 2013; NIMH, 2016).
Moreover, exposure to traumatic events can
influence children’s development in profound
ways, including delayed language and cognitive
development, decreased emotional regulation,
and poor school performance (Fairbank et al.,
2014).
Differential Diagnosis
Diagnosing PTSD can be difficult regardless
of the age of the patient. Patients with PTSD
generally have an increased incidence of other
psychological and physical conditions. In fact,
“individuals with PTSD are 80% more likely
than those without PTSD to have symptoms
that meet diagnostic criteria for at least one
other mental disorder” (APA, 2013, p. 280).
Other disorders, particularly major depres-
sive disorder, generalized anxiety disorder,
and substance use disorders, are frequently
comorbid with PTSD (Reardon et al., 2014),
as are traumatic brain injury and chronic pain
(Wynn & Benedek, 2017). Personality disor-
ders are also often seen in those diagnosed with
PTSD, including in particular avoidant per-
sonality disorder, paranoid personality disor-
der, obsessive-compulsive personality disorder,
and antisocial personality disorder (Reardon et
al., 2014). Individuals with comorbid disorders
typically present with more severe PTSD symp-
toms and may prove less amenable to treatment.
Because of the high comorbidity rates of
other disorders with PTSD and because many of
the symptoms exhibited with PTSD are similar
to those of other disorders, nurses at all levels
need to be aware of symptoms that may involve
PTSD and screen accordingly. Advanced prac-
tice registered nurses (APRNs), within their
scope of practice, can diagnose and intervene
appropriately. Knowledge and understanding of
PTSD criteria will be necessary to differentiate
PTSD from comorbid conditions.
Acute Stress Disorder
The primary difference between PTSD and
acute stress disorder is that in acute stress dis-
order, posttrauma symptoms both develop and
resolve within 4 weeks of the trauma, although
it can lead to a diagnosis of PTSD when symp-
toms do not resolve within 4 weeks. In contrast,
a diagnosis of PTSD involves symptoms occur-
ring at least 1 month after the traumatic event
(APA, 2013).
Adjustment Disorder
For these diagnoses, the stressor criterion
is the primary distinguishing characteristic.
Adjustment disorder may be the appropriate
diagnosis for an individual reacting to a stressor
of any severity (e.g., job loss, relocation, infi-
delity), whereas PTSD requires that the stressor
event be a life-threatening, injurious, or vio-
lent ordeal. With that being noted, adjustment
disorder may be the appropriate diagnosis for
an individual who has experienced an extreme
stressor but does not meet the other diagnostic
criteria for PTSD (APA, 2013).
Anxiety Disorders
The primary difference between these diag-
noses is that the arousal, avoidance, and irri-
tability symptoms of anxiety disorders are not
associated with a specific traumatic event.
Although obsessive-compulsive disorder and
PTSD involve recurrent, intrusive thoughts,
only those occurring in PTSD are related to an
experienced traumatic event (APA, 2013).
Depression
Depression may or may not be preceded by
a traumatic event, but it should be diagnosed if
other PTSD criteria are absent (APA, 2013).
Psychotic Disorders
The flashbacks that can occur in PTSD
need to be distinguished from illusions and
Understanding Posttraumatic Stress Disorder: From Assessment to Treatment
hallucinations that may happen with schizophre-
nia, depressive and bipolar disorders that have
psychotic features, and other disorders that are
a result of substance use/abuse or medications.
SPECIAL
CONSIDERATIONS
W ith the significant rate of trauma expo-
sure in many patients, nurses at all levels
may interact and provide care for individuals
who are at risk of or have PTSD. The risk of
PTSD can be greater for certain segments of the
population and will be discussed in the follow-
ing sections.
Pregnant and Postpartum Patients
Although pregnancy and childbirth are gen-
erally characterized as happy events, they may
not be positive experiences for everyone. A
trauma history, such as physical abuse, before
conception, or its occurrence during pregnancy
or delivery, can have a profound effect on mater-
nal and infant outcomes (Beck, 2016; Dekel,
Stuebe, & Dishy, 2017; Vignato, Georges, Bush,
& Connelly, 2017). These negative outcomes
include depression, limited prenatal care, reduced
mother-infant bonding, prematurity, and low
birth weight (Vignato et al., 2017). In a meta-
analysis of research articles, the prevalence of
PTSD during pregnancy was 3.3% in community
samples and 18.95% in high-risk samples; after
birth, the prevalence was 4.0% in community
samples and 18.5% in high-risk samples (Yildiz,
Ayers, & Phillips, 2017).
Perinatal PTSD can be defined as a “disor-
der arising after a traumatic experience, diag-
nosed any time from conception to 6 months
postpartum, lasting longer than 1 month, lead-
ing to specific negative maternal symptoms and
poor maternal-infant outcomes” (Vignato et al.,
2017, p. 1). Postpartum PTSD is considered
11
to be related to a traumatic event that occurred
during the childbirth experience, as a new
trauma, or as a trigger of a previous trauma
(Vignato et al., 2017). Hauff, Fry-McComish,
and Chiodo (2016) recommend that the stan-
dard of care during prenatal visits should be
an assessment of trauma exposure, depres-
sion, and PTSD symptoms at the initial visit
and during each trimester so that appropriate
medical and mental health interventions can
begin early. If the assessment indicates PTSD,
appropriate treatment and interventions should
be initiated. These treatments might include
cognitive-behavioral therapy (CBT), cognitive
processing therapy (CPT), prolonged exposure
(PE), eye movement desensitization reprocess-
ing (EMDR), and accelerated resolution therapy
(ART; Hernandez, Waits, Calvio, & Byrne,
2016; Resick, Monson, Gutner, & Maslef, 2014;
Waits, Marumoto, & Weaver, 2017). Nursing
interventions for symptom management might
include muscle relaxation, breathing retraining,
sleep hygiene, or all of these.
Children and Adolescent Patients
As previously discussed, assessing and diag-
nosing children and adolescents with PTSD is
challenging. Traumatic events can include child
abuse, neglect, emotional abuse, physical or
sexual assault, accidents, violent crime, natural
disasters, prior painful procedures, or the trau-
matic death or injury of a loved one (Hamblen
& Barnett, 2016; Rideout & Normandin, 2015).
Although the traumatic event is similar to
events in adults, the challenge is related to the
child’s or adolescent’s developmental age, in
relation to their understanding and ability to
process the event, and the variation of signs and
symptoms of PTSD across developmental lev-
els (Brown, Becker-Weidman, & Saxe, 2014).
In any case, it is critical for nurses to act upon,
assess, and intervene when there is an indication
12 Understanding Posttraumatic Stress Disorder: From Assessment to Treatment
of signs and symptoms of PTSD, to ameliorate
the long-term effects of PTSD.
In very young children (birth to preschool
age), reaching a diagnosis is especially chal-
lenging because children have zero to minimal
verbal skills and may not be able to put words
to the event or their feelings. PTSD at this age
involves the child’s attachment to the parent
or caregiver, and symptoms can manifest as
increased fussiness, irritability, and sleep prob-
lems. Trauma at these ages can disrupt devel-
opmental progressions and may actually cause
regression, such that children may begin to suck
their thumb or wet the bed when they already
avoid these habits (Barnett & Hamblen, 2016;
Brown et al., 2014).
School-aged children (aged 5 to 12 years)
use logic to understand events but may not be
able to accurately describe the traumatic event
in chronological order (Brown et al., 2014;
Hamblen & Barnett, 2016). Symptoms can
manifest as repetitive re-enactment of the event,
difficulty concentrating in school, sleep distur-
bances, and anger and hypervigilance (Brown et
al., 2014; Hamblen & Barnett, 2016).
Adolescents (aged 12 to 18 years) begin
to show similar signs and symptoms of PTSD
as an adult, such as aggressive and impulsive
behaviors (Rideout & Normandin, 2015). Some
adolescents may still exhibit childlike signs and
symptoms (Rideout & Normandin, 2015) and
show regression to childhood coping strate-
gies such as separation anxiety or bedwetting
(Brown et al., 2014). Adolescents can have
cognitive troubles (such as focus, concentra-
tion, and memory) that manifest as declining
performance in school (Brown et al., 2014).
They can also exhibit emotional symptoms,
such as numbing, guilt, and depression (Rideout
& Normandin, 2015).
Older Adult Patients
Little is understood regarding PTSD in
older adults, those 65 years of age and older.
Research has typically focused on those with
a history of military or combat experience,
Holocaust-related trauma in young adulthood,
and those who experienced natural or man-
made disasters (Cook, Spiro, & Kaloupek,
2014). Older adults also acknowledge similar
traumatic events as their younger counterparts,
including witnessed violence, childhood or cur-
rent physical or sexual assault (or both), and
their or a loved one’s life-threatening illness
(Bodner, Hoffman, Palgi, & Shrira, 2017; Cook
et al., 2014). With an understanding of the nor-
mal developmental changes that occur naturally
in older adults, nurses need be aware of cogni-
tive decline and the potential for accelerated
biological aging that can come from trauma
and PTSD and assess accordingly (Cook et al.,
2014). Longevity brings the potential for a life-
time history of experiencing a traumatic event, a
history of untreated or treated PTSD, or a first-
time exposure and diagnosis of PTSD (Cook
et al., 2014), and nurses are in the ideal place
to identify, intervene, and promote successful
aging in this cohort of individuals.
Patients Who Are Veterans
PTSD in veterans, as it pertains to those
who have experienced combat, has been exten-
sively researched and is one of the most common
psychiatric conditions among service members
returning from Iraq and Afghanistan (Fulton
et al., 2015). Recently, increased research has
examined differences related to deployment
stressors and PTSD for men and women veter-
ans and suggests that “military sexual trauma”
has been reported more by women and linked to
onset of PTSD (Street, Gradus, Giasson, Vogt,
& Resick, 2013; Norris & Slone, 2014, p. 111).
Veterans are at an overall increased risk of devel-
oping PTSD, in addition to adjustment disorders,
Understanding Posttraumatic Stress Disorder: From Assessment to Treatment
depression, anxiety disorders, and substance
abuse (Hanrahan et al., 2017). This overlap of
diagnoses can make assessing and diagnosing
of PTSD challenging in the veteran population,
especially if individuals do not disclose their mil-
itary history. Nurses need to be aware of patients
who have served in the military and ask them
about military service if an individual exhibits
signs and symptoms of PTSD or any other psy-
chological disorder (Hanrahan et al., 2017.
In addition to the previously discussed
assessment tools, several tools have been
designed specifically for use with veterans. The
first is the Mississippi Scale for Combat-
Related PTSD, developed to assess combat-
related PTSD symptoms (Reardon et al., 2014);
the Deployment Risk and Resiliency Inventory
– 2 , developed by staff at the Veterans
Administration’s National Center for PTSD
(Vogt et al., 2013); and the PTSD Checklist
for DSM-5 (PCL-5), another self-report tool
that screens and monitors PTSD symptoms
(Hanrahan et al., 2017; Blevins, Weathers,
Davis, Witte, & Domino, 2015). The use of any
of these assessment tools can be done by nurses
trained in the use of the tool and can be the first
step to get a veteran into treatment.
Lesbian, Gay, Bisexual, and
Transgender Patients
In 2017, preferred terminology is LGBTQI
(lesbian, gay, bisexual, transgender, questioning,
intersex), however; recently published research
has focused on the lesbian, gay, bisexual, and
transgender population. It is well established
that an individual, regardless of age, who
identifies as a sexual minority has an increased
risk of vic- timization and trauma across their
lifetime and an increased risk of developing
PTSD. Trauma events can include abuse and
neglect as a child (Smith, Armelie, Boarts,
Brazil, & Delahanty, 2016); bullying
(Beckerman & Auerbach, 2014; Dank,
Lachman, Zweig, & Yahner, 2014), and
13
physical or sexual abuse (Smith et al., 2016),
which in turn can lead to depression, substance
use, and increased risk of suicide (Smith et al.,
2016). For example, adolescents struggling with
their sexual orientation and identity are at an
increased risk of bullying and violence at school
and also violence in their dating relationships
(Dank et al., 2014), which can lead to PTSD.
TREATMENT OF PTSD
P TSD is treatable, and a variety of effective
psychological and pharmacological inter-
ventions are available, most of which can take
place on an outpatient basis. However, as with
other mental disorders, if a person is a danger to
self or others, inpatient treatment is likely
recommended. Management and treatment is
team-based and begins with a thorough medi-
cal and physical examination when possible, an
extensive history interview, and an individual-
ized treatment plan developed in cooperation
with the patient. Other members of the team
may include a physician (a primary care pro-
vider), a psychiatrist or a psychologist (or both),
a social worker, an art/music/play therapist, and
a care manager. Working with patients, espe-
cially those who have experienced a traumatic
event or are trauma survivors, can be triggering
and also emotionally and mentally taxing on
nurses at all levels. It is imperative that nurses
initiate self-care techniques and seek help to
prevent their own development of symptoms or
diagnosis of PTSD (or both), or another mental
health disorder.
Treatment of PTSD involves a variety of evi-
dence-based psychosocial therapies, psychoedu-
cation, symptom management interventions, and
pharmacologic treatment options. A competent,
compassionate registered nurse (RN) or APRN
who is skilled in dealing with PTSD is a critical
team member in managing and treating patients
14 Understanding Posttraumatic Stress Disorder: From Assessment to Treatment
who have a diagnosis of PTSD. Nurses may be
unaware of the cues that may indicate PTSD and
may be uncomfortable (within their scope of prac-
tice) with assessing, diagnosing, referring, and
man- aging or treating patients with PTSD.
Education and training regarding PTSD and its
treatment are critical to improve nurses’ comfort
and skills to pro- vide optimal outcomes for their
patients.
Therapeutic Goals
After a patient has completed the initial
screening and assessment process and received
a diagnosis of PTSD, the RN and the APRN
should assist and guide the client when develop-
ing an appropriate, attainable set of therapeutic
goals. Typically, the goals of therapy for indi-
viduals with PTSD include decreasing distress-
ing symptoms, improving daily functioning, and
enhancing self-coping techniques. These initial
stages of therapy may also involve psychoeduca-
tion about the nature of PTSD for the patient, the
people in the patient’s close relationships, and
family members. Additionally, psychoeducation
for the patient on trauma-specific treatments may
help prepare individuals for treatment and reduce
attrition once treatment is started. This factor is
particularly important when treating children
who have experienced a traumatic event.
Therapies
Because the pathophysiology of PTSD is
believed to include various combinations of fac-
tors, one treatment does not fit everyone. No
single or combination treatment has been estab-
lished as successful across the board. For adults,
multiple evidence-based psychotherapies have
been found to be efficacious in treating PTSD,
including cognitive-behavioral therapy (CBT),
cognitive processing therapy (CPT), prolonged
exposure (PE), eye movement desensitization
reprocessing (EMDR), and accelerated resolution
therapy (ART; Hernandez et al., 2016; Resick et
al., 2014; Waits et al., 2017). Oftentimes these
are conducted as stand-alone therapies, although
outcomes may be improved by combining spe-
cific components of a therapy or a complete
additional therapy (Resick et al., 2014). Resick
and colleagues (2014) found that the best psy-
chotherapeutic approaches for treating PTSD are
personalized and include ongoing assessment to
determine the needed length of treatment.
Determining the optimal psychosocial treat-
ment for children involves decisions regarding
the type of trauma experienced, the potential of
parental involvement inflicting the trauma, if
the parent experienced the same trauma as the
child, or whether parents have their own his-
tory of trauma, all of which can affect the type
of therapy chosen and its success. According to
the National Child Traumatic Stress Network,
several core concepts are shared by the most
effective treatments for children (see Table 1).
Evidence-based CBT for children can be done
with a parent, such as child-parent psychother-
apy, or separate therapy from parents such as
trauma-focused CBT (Cohen & Mannarino,
2014). Cognitive-behavioral interventions for
trauma in schools is a group therapy that does
not include parents (Cohen & Mannarino,
2014). For treatment of children, a school nurse,
with specific training, could provide individual
or group therapy at school, which can
improve participation. If the school has a
school-based health center on-site, it is also
possible that a social worker or an APRN could
provide ther- apy. The provider team of the
school nurse, the APRN, and the social worker
could provide comprehensive treatments at
school and commu- nicate with the patients’
primary care provider or psychiatrist to improve
patient outcomes.
Cognitive-Behavioral Therapy
The primary type of psychotherapy sup-
ported both by clinicians and research stud-
ies is cognitive-behavioral therapy, or CBT
(U.S. Department of Veterans Affairs, 2017c).
Understanding Posttraumatic Stress Disorder: From Assessment to Treatment 15

TABLE 1: CORE COMPONENTS OF INTERVENTIONS

• Motivational interviewing (to engage clients)

• Risk screening (to identify high-risk clients)
• Triage to different levels and types of intervention (to match clients to the interventions that will most
likely benefit them/they need)
• Systematic assessment, case conceptualization, and treatment planning (to tailor intervention to the
needs, strengths, circumstances, and wishes of individual clients)
• Engagement/addressing barriers to service-seeking (to ensure clients receive an adequate dosage of
treat- ment in order to make sufficient therapeutic gains)
• Psychoeducation about trauma reminders and loss reminders (to strengthen coping skills)
• Psychoeducation about posttraumatic stress reactions and grief reactions (to strengthen coping skills)
• Teaching emotional regulation skills (to strengthen coping skills)
• Maintaining adaptive routines (to promote positive adjustment at home and at school)
• Parenting skills and behavior management (to improve parent-child relationships and to improve child
behavior)
• Constructing a trauma narrative (to reduce posttraumatic stress reactions)
• Teaching safety skills (to promote safety)
• Advocacy on behalf of the client (to improve client support and functioning at school, in the juvenile
justice system, and so forth)
• Teaching relapse prevention skills (to maintain treatment gains over time)
• Monitoring client progress/response during treatment (to detect and correct insufficient therapeutic gains
in timely ways)
• Evaluating treatment effectiveness (to ensure that treatment produces changes that matter to clients
and other stakeholders, such as the court system)
Note. From National Child Traumatic Stress Network. (n.d.). National Child Traumatic Stress Network empirically supported treatments and
promising practices. Retrieved from http://nctsn.org/training-guidelines. Reprinted with permission.
Layne, C. M., Strand, V., Popescu, M., Kaplow, J. B., Abramovitz, R., Stuber, M., … Pynoos, R. S. (2014). Using the Core Curriculum on
Childhood Trauma to strengthen clinical knowledge in evidence-based practitioners. Journal of Clinical Child and Adolescent Psychology,
43, 286-300. doi:10.1080/15374416.2013.865192
Layne, C. M., Abramovitz, R., Stuber, M., Ross, L., & Strand, V. (2017, January). The Core Curriculum on Childhood Trauma: A tool for prepar-
ing a trauma-informed mental health workforce. Traumatic StressPoints, 31, 1-8. Retrieved from http://sherwood-istss.informz.net/informzdataser-
vice/onlineversion/ind/bWFpbGluZ2luc3RhbmNlaWQ9NjI1MTUwNCZzdWJzY3JpYmVyaWQ9MTA0NDYxODQ0MQ

Cognitive-behavioral therapy is a broad cat- management and psychoeducation can be safely

egory of therapies that focuses on behavioral
and cognitive interventions (Cusack et al., 2016)
and includes exposure-based interventions,
cognitive interventions, psychoeducation, and
symptom management interventions. Cognitive-
behavioral therapy may occur in either an indi-
vidual or a group setting and is typically done in
8 to 12 weekly sessions lasting 60 to 90
minutes. Many of the therapies to be discussed
require a specially trained provider,
including nurse practitioners, although much
of the symptom
performed by nurses at all levels and scope of
practice. Nurses are important members of the
interdisciplinary care team and play a critical
role when working with patients with PTSD.
An RN or APRN may be the provider who is
helping to coordinate or provide treatments, and
APRNs may be prescribing pharmacotherapy.
Additionally, as members of an interdisciplin-
ary care team, nurses of all levels can provide
reinforcement of treatment if they have an
under- standing of the different treatments being
utilized
16 Understanding Posttraumatic Stress Disorder: From Assessment to Treatment
by providers on their teams. This relationship
with patients can be an important part of
helping patients to maintain treatment regimens
because dropout rates are high for patients with
PTSD.
Exposure-Based Interventions
Exposure therapy techniques have received
empirical support regarding their effective-
ness in the treatment of PTSD (Resick et al.,
2014). Exposure-based interventions, such as
PE, involve guided and repeated exposure to
trauma-based images and thoughts in a safe,
structured way (Shalev, Liberzon, & Marmar,
2017) to eliminate the conditioned emotional
response to traumatic stimuli (Cusack et al.,
2016). For example, during PE, the patient is
taught a self-regulating behavior, such as deep
breathing, and how to communicate and quan-
tify distress. Then the patient progressively
recalls the traumatic event, especially the ele-
ments he or she avoids, using the deep breath-
ing and communication of distress with the
therapist. This sequence is repeated until the
memories are no longer intolerable and not
avoided (Shalev et al., 2017). In addition to
the imaginal exposure of the trauma in ses-
sion, patients are assigned in vivo exposure
homework assignments that involve exposure to
avoided situations and activities associated with
avoidance stemming from the trauma. These
exposures are done in a hierarchical fashion and
with strict guidance from the provider. After
both the imaginal and in vivo exposures, the
provider and the patient debrief and process the
experience while the provider provides cogni-
tive restructuring interventions.
Eye movement desensitization and repro-
cessing (EMDR) is an imaginal exposure tech-
nique in which the patient holds an image of the
traumatic memory while engaging in bilateral
eye movement, such as moving the eyes rap-
idly back and forth while following the thera-
pist’s finger (Cusack et al., 2016). The patient
describes the types of thoughts and feelings that
arise after each set of eye movements. This
process is continued until the client’s distress
upon exposure to the images is reduced and
desensitization has occurred (Cusack et al.,
2016). Although evidence supports the effi-
cacy of EMDR in reducing symptoms of PTSD
(Cusack et al., 2016), research needs to be done
to see if combining EMDR and a cognitive
intervention improves outcomes (Resick et al.,
2014). Prolonged exposure and EMDR can be
provided by nurses at all levels, although they
would require special training to ensure fidelity
of the treatment.
Cognitive Interventions
Cognitive therapy is designed to help
patients identify posttraumatic distorted think-
ing and modify existing beliefs so that they can
cope and change problematic behavior (Cusack
et al., 2016; Shalev et al., 2017). For example,
rape victims may erroneously believe that they
are to blame for being raped and consequently
experience severe feelings of shame. Similarly,
combat veterans may feel a great deal of guilt
resulting from their belief that they “should
have done more” to help their friends who were
killed during an attack by the enemy. Cognitive
interventions challenge the dysfunctional cog-
nitions underlying these distressing emotions.
Cognitive processing therapy (CPT) is an exam-
ple of a cognitive therapy and includes psy-
choeducation, at times a written account of the
traumatic event, and cognitive restructuring to
help patients identify distorted thinking and
modify beliefs and behaviors that the patient has
developed regarding the event (Cusack et al.,
2016; Lancaster et al., 2016). CPT focuses on
understanding how the trauma affected an indi-
vidual’s beliefs about the self and others. Often,
these beliefs are negatively biased following
a trauma, and the therapist helps the patient to
examine these negative thoughts systematically
Understanding Posttraumatic Stress Disorder: From Assessment to Treatment
and challenge them to generate more balanced
thoughts. CPT focuses on five common themes
of negative cognitions: safety, trust, power and
control, esteem, and intimacy (Resick, Monson,
& Chard, 2017). Although nurses at all levels
can provide cognitive interventions, they may
want to obtain training specific to this modality
before working with patients.
Psychoeducation
Psychoeducation refers to teaching the cli-
ent and his or her family members about the
nature of PTSD, its symptoms and expected
course, and the various treatments available.
Psychoeducation can be particularly important
during the earlier stages of therapy but is typi-
cally used throughout the course of treatment
as new issues arise. Psychoeducation can be
used during individual or group therapy and is
typically included in prolonged exposure and
CPT sessions (Suzuki & Tanoue, 2013). Nurses
at all levels are trained in providing patient
education and are ideally situated to provide
psychoeducation to patients. In many instances,
a nurse is the first person that patients will talk
to about their trauma, and a nurse can provide
psychoeducation quickly. During individual
or group therapy that is provided by a nurse,
such information can be reinforced as needed.
Additionally, patients may have difficulty shar-
ing what they learned about PTSD with their
family or people providing social support. This
is an important area where nurses may be able
to intervene and help the patient’s family under-
stand PTSD and trauma-focused treatment in
order to help reduce communication issues.
Symptom Management
Nurses and nursing interventions are impor-
tant in the symptom management of PTSD and
can be provided, as needed, whenever the nurse
has contact with the patient. Symptom manage-
ment involves helping the patient learn how to
17
deal with the stress and anxiety of the trauma
through a variety of coping skills. Stress inocu-
lation training, a relaxation-based psychother-
apy, includes a variety of anxiety-management
strategies such as breathing retraining, muscle
relaxation, negative-thought-stopping, and cog-
nitive restructuring (Lancaster et al., 2016), all
of which can be performed by nurses at all lev-
els, across settings.
Breathing retraining involves two basic com-
ponents: breathing control and concentration.
For breathing control, one should find a quiet,
comfortable spot, and then work on breathing
smoothly and easily from the diaphragm. Once
the breathing becomes regular and smooth, the
individual can concentrate on his or her breath
by counting the number of in-breaths until he
or she reaches 10 and then starting over. As the
individual becomes more comfortable with this
technique, he or she can start to slow the number
of breaths. This technique is particularly useful in
helping the client relax and avoid hyperventila-
tion and its ill effects.
Muscle relaxation teaches clients to system-
atically relax different muscle groups as a way
of controlling fear, anxiety, and tension. This
technique typically involves tensing groups of
muscles, then allowing those muscles to relax.
The client then focuses on the difference between
the tense and relaxed states, learning how to
induce muscle relaxation when necessary.
Thought stopping, although a component of
stress inoculation training, has not always
shown to be efficacious in the treatment of
PTSD symptoms (Cusack et al., 2016) and is
not currently recommended as a first-line treat-
ment (Goetter & Marques, 2016). It is a process
whereby patients who are experiencing intrusive
thoughts do their best to stop those thoughts
through various means, such as shouting over
them (out loud or to themselves, “STOP!”),
using visualization techniques, or snapping a
18 Understanding Posttraumatic Stress Disorder: From Assessment to Treatment
rubber band on their wrist when the unwanted
thoughts occur. If this approach is used, it
would need to be paired with another cognitive
intervention to help reappraise the initial nega-
tive thought.
Cognitive restructuring involves increas-
ing the patient’s sense of mastery over anxiety.
After patients have mastered one or more relax-
ation skills, they are then challenged by anxiety-
provoking situations where they apply their
newly mastered skills (Lancaster et al., 2016).
Because many individuals with PTSD have
sleep problems, it is important for nurses to be
able to educate their clients about good sleep
hygiene and habits. These habits include keep-
ing a regular sleep schedule, limiting naps,
exercising earlier in the day, winding down
at the end of the day, and spending less time
in bed doing things other than sleep and sex
(e.g., watching television). In addition to these
good sleep-habit techniques, clients should be
encouraged to reduce caffeine, limit alcohol
consumption and smoking, and avoid narcotics
and other sedatives.
Another technique to change a patient’s
thought process is positive thinking and self-
talk. This technique refers to teaching patients
to replace their negative thoughts with positive
or more balanced beliefs as a way of coping
with stress. For example, instead of thinking,
“Oh, no, I have to drive by the place where
the accident happened. I just know I’m going
to have a flashback,” the client could think, “I
have learned lots of new skills on how to deal
with this. I know I can use them when I go by
there and be just fine.”
Assertiveness training is another important
skill to teach many individuals who endure
PTSD. Many of them have impaired rela-
tionships because of their avoidance of emo-
tion. Assertiveness training can help these
individuals communicate more effectively in
their relationships. Assertive communication
involves using assertive body language, such
as direct eye contact and clear speech, as well
as “I statements,” such as “I feel that…” or “I
want this….” Using this form of communication
can help clients with PTSD express themselves
appropriately with others, thereby improving
the quality of their relationships.
Nurses can also promote symptom man-
agement with referral or provision of comple-
mentary therapies with appropriate training.
These therapies can include meditation, yoga,
acupuncture, and mind-body practices of energy
therapy, healing touch, and guided imagery
(Strauss, Lang, & Schnurr, 2017).
Psychopharmacology
Psychotherapeutic interventions are the first
and most supported options for treating PTSD,
but many pharmacological treatments are avail-
able. A few of the medications used in the treat-
ment of PTSD will be discussed in this section,
and a more extensive list is included in the
Appendix. All of the medications discussed
are for reference only. Psychopharmacological
treatments are frequently evaluated, changed,
or discontinued, and new medications are intro-
duced. Nurses who are prescribers, such as cer-
tified nurse specialists or APRNs, should refer
to current treatment guidelines and detailed pre-
scribing information for up-to-date information
on any medication that they prescribe.
Although drug therapy for PTSD has evolved
significantly over the past decade, many factors
complicate the use of medications for PTSD.
First, most of the drugs used for PTSD (such as
antidepressants, antihypertensives, anticonvul-
sants, and anxiolytics), were developed for other
conditions (Friedman & Bernardy, 2017). For
example, randomized clinical trials have primar-
ily tested the efficacy of using antidepressant
and anxiolytic drugs, but neither of these types
Understanding Posttraumatic Stress Disorder: From Assessment to Treatment 19

of medications was developed specifically for

Researchers are also looking at the possibil-
the physiological mechanism thought to underlie
ity of using medication to prophylactically treat
PTSD (Friedman & Davidson, 2014). Second,
and prevent development of PTSD. According
clients with PTSD commonly have multiple
to Friedman & Bernardy (2017) and Roque
symptoms and comorbid conditions, including
(2015), these medications are administered
mood and anxiety disorders that complicate clini-
within hours of the traumatic event, and the
cal psychopharmacological treatment consid-
most promising ones include the following:
erations. Additionally, little is known about the
safety and efficacy of medications for the treat- 1. Hydrocortisone: to decrease cortisol and
ment of PTSD in children, adolescents, and older stress response
adults (Friedman & Davidson, 2014). 2. Propranolol: to reduce the physiological
Currently, sertraline and paroxetine are response
approved by the U.S. Food and Drug Admin- 3. Opioids: for pain relief and to reduce physi-
istration for use in the treatment of adults with ologic response
PTSD. Both of these medications are from a
As with all medications, the particular risks
class of antidepressants known as selective
and side effects of their use must be examined
serotonin reuptake inhibitors (SSRIs). Although
and communicated to patients. Some issues the
not designed specifically for the treatment
prescriber must consider include: Will patients
of PTSD, these types of medications may be
take the medication? Do the patients have other
helpful in managing PTSD symptoms. SSRIs
health problems that they take medication for?
are currently considered the pharmacological
Do patients have concerns about the drug or
treatment of choice for individuals with PTSD
mistrust the provider? Is a disability present?
(Friedman & Davidson, 2014). These medica-
Can patients tolerate the effects of the medica-
tions have proved effective in the treatment of
tion and the side effects? Does the medication
intrusive thoughts; flashbacks; trauma-related
reduce the symptoms? Do patients have sub-
fears; panic and avoidance; general anxiety;
stance use issues that may interfere with the
numbing or detachment from others, with loss
chosen psychopharmacotherapy?
of interest; irritability with angry outbursts; dif-
ficulty concentrating; and guilt and shame.
Other medications may also be useful in NEW RESEARCH AND
treating PTSD; however, they have not received INTERVENTIONS
as much empirical scrutiny as have the SSRIs.
Previous research has indicated that the fol-
lowing medications have shown some efficacy A lthough PTSD treatment is effective for
many individuals, some patients still
qualify for a diagnosis of PTSD at treatment’s
in ameliorating PTSD symptoms: serotonin-
end and during later follow-up visits (Resick
norepinephrine reuptake inhibitors (SNRIs)
et al., 2014). Therefore, it is important that
such as venlafaxine, antiadrenergic agents such
nurses work closely with the patient and other
as propranolol, anticonvulsant agents such
members of the multidisciplinary care team
as carbamazepine, and atypical antipsychotic
to assess how treatment is going and provide
medications such as risperidone (Friedman &
options if progress is not being made. Treatment
Bernardy, 2017; Friedman & Davidson, 2014).
needs to be individualized to maximize success
and reduce the potential for recurring PTSD
20 Understanding Posttraumatic Stress Disorder: From Assessment to Treatment
throughout the patient’s life. The ultimate goal
is for the patient to be free of PTSD symptoms
and also develop positive coping skills to utilize
for any future trauma exposure to reduce a sub-
sequent PTSD diagnosis.
Some new and innovative treatments and
ways to provide treatment show success in reduc-
ing symptoms and are acceptable to patients.
Accelerated resolution therapy (ART) is a
relatively new psychotherapy that has shown
promising results in resolving many psychiatric
symptoms (Waits et al., 2017). ART is an imag-
inative therapy, performed by licensed thera-
pists, that helps patients rescript their traumatic
memory and associated physical sensations,
cognitions, emotions, images, and perceptions
(Hernandez et al., 2016).
New research has focused on compassion-
based therapy for PTSD as well (Au et al.,
2017), because a growing body of research
shows that shame is a strong driver of the devel-
opment and maintenance of PTSD. Building up
self-compassion for individuals has been shown
to reduce this shame and, in turn, the PTSD
symptoms. Compassion-based therapy for
PTSD includes techniques such as guided
loving-kindness meditation, compassionate self-
talk, and nonjudgmental awareness of thoughts
and feelings, especially suffering. Preliminary
evidence shows promising results for building
self-compassion as a treatment for PTSD.
Additionally, research has found that writ-
ten exposure therapy may be an alternative
intervention rather than talking about the trauma
with a provider (Sloan, Marx, Bovin, Feinstein,
& Gallagher, 2012; Sloan, Lee, Litwack,
Sawyer, & Marx, 2013). Written exposure ther-
apy starts with a session in which the patient is
provided with psychoeducation about PTSD and
the rationale for treatment. After these topics are
discussed, patients are asked to write about their
trauma during each session, including as
much detail as they can remember. The direc-
tions also prompt patients to write about what
they were thinking and feeling when they
were experiencing the event, as well as how
the trauma has affected their lives and poten-
tially changed the way they interact with others.
Additionally, perspective taking is included,
which allows for individuals to distance them-
selves from the trauma. After the patient is
done with the writing (which typically takes
30 to 40 minutes), the therapist returns and the
patient and the therapist process the experience
of writing about the trauma, which takes 10
minutes or less. Written exposure therapy has
been shown to be effective in reducing PTSD
symptoms in both veterans and civilians.
For veterans, the addition of canine assis-
tance (service dogs, therapy dogs, or emotional
support dogs) is showing promise in reduc-
ing PTSD symptoms and facilitating recovery
(Krause-Parello, Sarni, & Padden, 2016). Also,
for older veterans, research has been conducted
regarding the addition of physical activity coun-
seling to improve health-related quality of life
and leisure-time activity for those diagnosed
with PTSD. The increase in physical activity
can improve cardiovascular, metabolic, and
functional ability and the psychological health
of older veterans (Hall et al., 2016).
Treatment and support is being provided
with telehealth and Internet-based interventions.
Utilizing telehealth and the Internet can increase
accessibility to treatment and support services,
especially for patients who live in remote loca-
tions or have significant avoidance symptoms
and resist going to a clinic (Boasso, Kadesch, &
Litz, 2014; Morland, Hoffman, Greene, & Rosen,
2014). Many of the CBT therapies can be pro-
vided either by telehealth or as guided Internet
interventions (Boasso et al., 2014). Telehealth
delivery of treatment options includes video-
conferencing, telephone-based interventions,
Understanding Posttraumatic Stress Disorder: From Assessment to Treatment
Web-based services, and even the use of mobile
devices (Morland et al., 2014). The efficacy of
Internet interventions has been established for
prevention, treatment, and maintenance of treat-
ment goals, although more research is needed to
establish the benefit of Internet interventions ver-
sus standard care (Boasso et al., 2014).
CASE STUDY 1
J ulie is a 17-year-old high school student
who presents to the primary care office for
her annual physical and brings her mother to
the appointment. Julie completes the history
form on her own, and the RN reviews the form
before Julie sees the APRN. Julie plays
soccer and basketball; this will be her senior
year on the teams, and she has been named as
the cap- tain for both teams. The RN notes that
Julie has responded “yes” to having trouble
with sleep, increased irritability, and difficulty
concentrat- ing during class. Julie confides in
the RN that she may fail her classes but does
not really care at this moment. The RN
becomes concerned because she knows that
Julie wants to go to col- lege for computer
engineering and takes pride in doing well.
The RN asks Julie if she will be on the soccer
and basketball teams this year and is surprised
when Julie states that she really is not
interested in playing this year. The RN asks
Julie if anything happened before the start of
her symptoms. Julie responds that her best
friend died in a motor vehicle accident about 3
months
ago and she cannot stop thinking about it.
Questions
1. What additional information related to
Julie’s symptoms does the RN ask Julie and
her mother?
2. What things do the RN and the APRN dis-
cuss related to a possible diagnosis and a
plan for Julie?
21
Responses
1. According to the DSM-5 criteria for PTSD,
the RN needs to confirm when the symp-
toms started and how long the symptoms
have lasted. She can also ask if there are
any other symptoms that Julie has not
mentioned, such as experiencing guilt or
self-blame, withdrawing from her usual
activities, or avoiding friends. The RN also
should inquire whether Julie was involved
in the accident, witnessed it, or heard about
it from someone else. The RN asks if Julie
has received any counseling or talked with
anyone regarding the accident and her feel-
ings and symptoms. With this additional
information, the RN can let Julie and her
mother know that she will talk with the
APRN and that they will discuss a plan of
care for Julie.
2. The RN shares all of the information that
she was able to get from Julie and her
mother related to the accident and Julie’s
subsequent symptoms. The nurses discuss
what is needed for assessment and diag-
nosis as well as a potential plan for treat-
ment that will include the multidisciplinary
team available at the health center. They
both believe that Julie is experiencing PTSD
secondary to the death of her friend in the
accident and that a comprehensive assess-
ment should be conducted to determine the
optimal treatment plan. They also discuss
the need to rule in or rule out depression
because depression can affect the treatment.
The APRN will do a PTSD assessment
as well as a depression screen and share
the results with Julie and her mother so
that they can develop a treatment plan that
is amenable to Julie and her mother. The
APRN shares that a comprehensive treat-
ment plan might include counseling/therapy,
medication, and suggestions to improve
22 Understanding Posttraumatic Stress Disorder: From Assessment to Treatment
sleep, concentration, and focus. She also lets
Julie and her mother know that in addition
to her and the RN, the other members of the
team would include the physician, a social
worker, and a psychiatrist.
CASE STUDY 2
A lex is a 30-year-old Army veteran with a 1-
year history of PTSD. Alex served in
Afghanistan and experienced many combat mis-
sions, including surviving an injury from an
improvised explosive device, after which he was
honorably discharged. He was diagnosed with
PTSD by a mental health provider shortly after
returning to the United States about a year ago.
Since that time, Alex had sporadic therapy ses-
sions, with his last encounter about 10 months
ago. He felt that he did not need therapy and
that things were going fairly well for him at that
time because he started his civilian life with a
new job and a recent engagement to his long-
time girlfriend.
Alex has come to the health center because
over the past month or so, he has had trouble
sleeping because of nightmares related to his
injury. He states that as soon as he falls asleep,
it is as if a movie of the entire day of the event
starts playing in his head, and he wakes up in
a cold sweat and does not want to go to sleep
again. He also reports that he is starting to
have trouble at work because he is easily agi-
tated by his coworkers and has angry outbursts
that include yelling and throwing things. He
states that he has significantly increased his
alcohol intake and can consume 6 to 12 beers
almost every day of the week. Another major
concern is that his current relationship with his
fiancé is in jeopardy because of his excessive
drinking and angry outbursts. He acknowledges
that he is having trouble with PTSD now and is
ready to commit to treatment.
Questions
1. What information is needed from Alex
before a treatment plan can be developed?
2. What would be a recommended treatment
plan? Would it include therapy, psychophar-
macology, other interventions, or all of
these?
Responses
1. Even though Alex has a history of a diagno-
sis of PTSD, he will need a
multidisciplinary team to do a
comprehensive assessment to determine the
optimal treatment plan for him at this time.
Nursing could take the lead on gathering
information. Alex should answer questions
regarding his previous treat- ment, type of
therapy, how many sessions he attended,
and medications and symptom management
interventions that were used (including if
any of them were effective). He will also
need to have a complete substance abuse
history gathered and an updated PTSD
screen. After the historical information and
his current symptoms and PTSD screen are
completed, a treatment plan can be devel-
oped with him, with other team members
from psychiatry, social work, and medicine
brought in as needed.
2. A recommended treatment plan would
include one or more cognitive-behavioral
therapies, depending on the success of pre-
vious therapies. The use of medications
would be determined by Alex and his men-
tal health APRN or psychiatrist, depending
on the symptom severity. Alex’s alcohol
consumption would need to be taken into
consideration and medication prescribed
accordingly. Alex may need treatment for
alcohol abuse, depending on the severity
of Alex’s alcohol consumption. Nursing
at all levels could be involved in symp-
tom management strategies, including sleep
hygiene, muscle relaxation, and
meditation.
Understanding Posttraumatic Stress Disorder: From Assessment to Treatment 23

Establishing an exercise program and

exploring having a canine therapy dog are
additional considerations.
CASE STUDY 3
the midwife was unable to initiate any treatment
or symptom management for Angela. Angela
does return for her next scheduled appointment,
which includes a cervical check because she is
approaching her due date. During the visit and
exam, Angela appears increasingly anxious,

A ngela, who is 25 years old, is newly

preg- nant with her first baby. She and her hus-
band are very happy and look forward to
and when the midwife tries to address Angela’s
anxi- ety, Angela becomes flustered and ends
the visit.
being parents. As Angela begins prenatal care,
Angela’s midwife is not available when
the RN assesses for a trauma history during
Angela goes into labor, and the baby is deliv-
the initial intake. Angela screens positive for a
ered by an obstetrician/gynecologist provider
history of sexual, physical, and emotional
who was on call at the hospital. The provider
abuse as a child that was perpetrated by her
did not know Angela and was unaware of the
stepfather. She received therapy as an
behavior exhibited during some of the prenatal
adolescent and young adult and was able to
visits. Angela did not exhibit any of the previ-
move forward in her life and have a healthy,
ous behavior and symptoms during the deliv-
loving relationship with her husband. Although
ery or while she was in the hospital, so there
she has disclosed her abuse history, she states
was no assessment or intervention performed
that she “does not want to discuss it” and
before discharge. Angela was discharged home
believes that she is “over it.” With the
with a healthy baby girl. At the 6-week post-
pregnancy diagnosis, Angela started to wonder
partum visit, it is noted that the baby is not
if she would be able to manage the delivery
gaining weight, and Angela indicates that she
and if she would be a “good” parent. Angela
stopped breastfeeding after being discharged
works full-time as a cashier at a local
from the hospital. The RN and the midwife talk
grocery store, which she enjoys, and has sup-
port from her coworkers. with Angela and her husband separately and
together to assess the situation. Angela’s hus-
As the pregnancy progresses, Angela begins
band reports that Angela does not attend to the
to have insomnia, trouble concentrating, and
infant’s cues when the infant is crying or needs
intrusive memories of the abuse. She reports
to be fed or changed. He feels that she cannot
that she has been arguing with her husband
be left alone with the baby, and he has had to
often, has quit her job, and really does not care
take a leave from his job to be at home. Angela
about anything. She continues to attend her
reports that she is having nightmares, does not
scheduled obstetric appointments but interacts
really care about the baby, and is scared that
less and less with any of the providers. The RN
she will do something to harm the baby.
becomes concerned during a normal obstetric
appointment when Angela appears unkempt, Questions
complains of fatigue, and has lost weight. The 1. What is the most likely diagnosis for Angela?
RN shares her concerns with the midwife who 2. What are options for a plan of care that
has been following Angela for her entire preg- the RN and the midwife may develop with
nancy. The midwife attempts to address the con- Angela and her husband?
cerns with Angela, but Angela abruptly leaves
the exam room and exits the health center, so
24 Understanding Posttraumatic Stress Disorder: From Assessment to Treatment
Responses
1. The most likely diagnosis is perinatal post-
traumatic stress disorder (PPTSD). The defi-
nition of PPTSD is a “disorder arising after
a traumatic experience, diagnosed any time
from conception to 6 months postpartum,
lasting longer than 1 month, leading to spe-
cific negative maternal symptoms and poor
maternal-infant outcomes” (Vignato et al.,
2017, p. 1). Angela has a history of child
abuse and has developed insomnia, intrusive
symptoms, and poor concentration early in
the pregnancy. She also exhibited avoidance
behavior by quitting her job. The negative
maternal symptoms include having insom-
nia, not caring about anything, and having
poor maternal-infant bonding and negative
infant outcomes, such as weight loss.
2. A comprehensive plan of care for Angela
could be initiated during prenatal care, dur-
ing the postpartum period, or during both;
and it could include therapy, symptom man-
agement, and pharmacology options (not
breastfeeding). It is critical to involve the
husband in the development and implemen-
tation of the plan of care so that he can sup-
port Angela and be supported during this
time. Unfortunately, during prenatal visits,
Angela was not receptive to treatment; she
left appointments abruptly without allow-
ing any discussion regarding her symptoms.
The RN and the midwife attempted multiple
times to get Angela to discuss her symptoms
so that they could develop a plan that would
address her symptoms and reduce negative
effects on the infant, but they were not able
to do so until Angela was receptive during
the postpartum visit.
SUMMARY
D espite its fairly recent introduction into
the DSM, PTSD has received a great deal
of clinical and research attention in the past
30 years. Although not everyone exposed to
an extreme, life-threatening stressor develops
PTSD, approximately 7% to 12% of the U.S.
population will develop PTSD within their life-
time. Clearly, this incidence rate highlights the
need for all health professionals, especially
nurses, to recognize the clinical signs and
symptoms related to PTSD and to intervene
effectively with clients who may experience
PTSD-related symptoms.
As described in the course, PTSD involves
four main sets of symptoms: persistent intru-
sive symptoms of the traumatic event, persis-
tent avoidance of event-related stimuli, negative
changes in cognitions and mood associated with
the event, and increased arousal. These symp-
toms typically cause significant impairment
in many areas of an individual’s life. Because
PTSD is frequently comorbid with other men-
tal health problems, thorough assessment and
differential diagnosis processes are critical in
establishing the most effective treatment plan
for the client. Cognitive-behavioral therapy and
pharmacotherapy have both proved effective in
treating individuals with PTSD. With that being
noted, approximately one-half of clients with
a PTSD diagnosis still qualify for that diag-
nosis at the conclusion of treatment or during
later follow-up visits. Given the proliferation of
research regarding psychotherapy and
pharmaco- therapy effectiveness, as well as the
role of biol- ogy and genetics in PTSD, it is
likely that new advances in the effort to treat
PTSD will be forthcoming. Nurses at all levels
are encouraged to stay informed about new
developments in the assessment, diagnosis,
management, and treat- ment of PTSD to
provide holistic care and pro- mote the best
outcomes for their patients.
 EXAMQUESTIONS
UNDERSTANDING POSTTRAUMATIC
STRESS DISORDER:
FROM ASSESSMENT TO TREATMENT
Questions 1–20

Note: Choose the one option that BEST answers each question.

1. Posttraumatic stress disorder (PTSD) 4. Which of the following theories about

was first included in the Diagnostic the causes of PTSD focuses on changes
and Statistical Manual of Mental involving the amygdala and release of
Disorders under its present name in stress hormones?
a. 1952. a. Learning theories
b. 1968. b. Schema theories
c. 1980. c. Biological theories
d. 2000. d. Genetic theories

2. The percentage of people in the United
States who will likely have PTSD sometime
during their lives is
a. 1% to 3%.
b. 7% to 12%.
c. 15% to 25%.
d. about 40%.
3. Which of the following is a true statement
about the incidence of PTSD?
a. Women are diagnosed with PTSD more
frequently than men are.
b. Men are diagnosed with PTSD more
frequently than women are.
c. Men and women have the same PTSD
diagnosis rate.
d. Children are diagnosed with PTSD more
frequently than adults are.
5. A risk factor for the development of PTSD is
a. a pre-existing mental health problem.
b. brain damage.
c. high socioeconomic status.
d. emotion regulation ability.
6. One of the DSM-5 criteria for PTSD is
a. adequate function in social
or occupational activities and
other activities.
b. the presence of symptoms for 21 days.
c. attraction to situations that are reminders
of the traumatic event.
d. persistent re-experiencing of a
traumatic event.

25 continued on next page

26 Understanding Posttraumatic Stress Disorder: From Assessment to Treatment

7. Which of the following symptoms indicates

increased arousal? 12. When clients with PTSD lose touch with
reality during a flashback, they are most
a. Persistent avoidance likely to believe that
b. Restricted emotions a. they were never involved in the event.
c. Insomnia b. they are actually reliving the event.
d. Depression c. the event is happening to someone else.
d. the event is no more than a dream.
8. PTSD is considered to have a delayed
expression if full criteria are not met
until at least 13. Hypervigilance, an increased awareness
of one’s surroundings and significantly
a. 2 weeks after the traumatic event. diminished ability to concentrate, is
b. 4 weeks after the traumatic event. characteristic of
c. 6 months after the traumatic event. a. negative cognition and mood symptoms.
d. 12 months after the traumatic event. b. hyperarousal symptoms.
c. re-experiencing symptoms.
9. Which of the following PTSD assessment d. physiological and intellectual symptoms.
tools is brief and efficient?
a. Brain imaging 14. Individuals with comorbid disorders may
b. Rorschach inkblot test prove less amenable to treatment and
c. Self-report questionnaires typically present with
d. Clinical interviews a. less severe PTSD symptoms.
b. more severe PTSD symptoms.
10. Which of the following findings in a client’s c. no somatic complaints.
history would suggest a diagnosis of PTSD? d. more somatic complaints.
a. Family history of depression
b. Reliving of a trauma 15. When preparing a differential diagnosis of
c. A high-stress lifestyle PTSD, which of the following should be
ruled out?
d. Suppression of appetite
a. Acute stress disorder
11. Which of the following triggers can be b. Decreased cognitive abilities
particularly difficult for clients with PTSD? c. Substance use disorders
a. Anniversaries of the date of the d. High hormone levels
traumatic event
b. The act of helping to prepare the 16. Postpartum PTSD is considered to be
individual treatment plan related to
c. Any and all social situations a. the uneventful delivery of healthy child.
d. Group therapy sessions b. a prior history of physical abuse.
c. a healthy relationship with the
baby’s father.
d. supportive friends and family.
Understanding Posttraumatic Stress Disorder: From Assessment to Treatment 27

17. The therapeutic approach typically

recommended for the treatment of PTSD is
a. cognitive-behavioral therapy.
b. psychodynamic therapy.
c. existential therapy.
d. gene therapy.

18. Stress inoculation training is a relaxation-

based psychotherapy that uses a variety
of anxiety-management strategies that can
be performed by nurses across all settings
and includes breathing retraining, muscle
relaxation, and
a. dance therapy.
b. cognitive restructuring.
c. acupuncture.
d. canine assistance.

19. Insomnia is a common sequela of a

traumatic experience; therefore, it is
important for nurses to provide information
about good sleep hygiene. An example of a
good sleep habit is
a. watching television in bed.
b. exercising right before going to bed.
c. limiting naps.
d. sleeping much later on weekends.

20. Which of the following is a true statement

about the course of PTSD?
a. Successful treatment occurs when PTSD
symptoms never resurface.
b. Improvement is generally rapid under
professional care.
c. The course of PTSD generally lasts less
than 1 month.
d. PTSD can present again even after
successful treatment.

This concludes the final examination.

Please answer the evaluation questions found
on page v of this course book.
 APPENDIX

MEDICATIONS FOR PTSD

Typical Daily
Class Medication Dose Indication
Antiandrenergic Propranolol 40-160 mg Propranolol is used to prevent PTSD by
blocking fear memory development.
Prazosin 4-15 mg Prazosin is used for sleep disturbances
and nightmares.
Anticonvulsants Topiramate 200-400 mg Sleep disturbance and nightmares.
May be helpful for patients with comorbid
alcohol use disorders.
May be beneficial for those who fail
first-line treatments.
Atypical Risperidone 4-16 mg Adjunctive treatment.
antipsychotics Used for coexisting psychotic or mood disorder.
Glucocorticoids Hydrocortisone iv or oral Prevention of PTSD by decreasing
stress symptoms.
Neuropeptides Oxytocin Intranasal Mediate emotional and stress response.
Prevention of PTSD.
Augmentation of psychotherapy for PTSD.
Novel agents Marijuana Inhaled May reduce PTSD symptoms across all
Ketamine iv major symptom clusters.
Reduce aggressive behavior.
Work as anxiolytics and antidepressants.
Depression.
Suicidal ideation.
Opioids Morphine Prevention of PTSD when given directly
following the event.
Inhibit fear-related memory development.
Other Mirtazapine 15-45 mg Insomnia.
antidepressants Depression.

continued on next page

29
 Appendix—
30 Understanding Posttraumatic Stress Disorder: From Assessment to Treatment

Typical Daily
Class Medication Dose Indication
Serotonergic Trazodone 150-600 mg Insomnia.
antidepressant Depression.
SNRI Venlafaxine 75-225 mg Reduces PTSD symptoms across all
symptom clusters.
Depression.
SSRI Paroxetinea 10-60 mg Reduces PTSD symptoms across all
Sertralinea 50-200 mg symptom clusters.
Citalopram 20-60 mg Depression.
Panic disorder.
PTSD = posttraumatic stress disorder; SNRI = serotonin-norepinephrine reuptake inhibitors; SSRI = selective serotonin reuptake inhibitors.
a
Paroxetine and sertraline are the only medications that have had enough positive clinical trials to obtain approval from the U.S. Food and Drug
Administration for treatment of PTSD. Other medications are used off-label for treatment of PTSD because they may improve symptoms but need
more random controlled trials to obtain approval for treatment of PTSD.
Note. Adapted from Friedman, M. J., & Davidson, J. R. T. (2014). Pharmacotherapy for PTSD. In M. J. Friedman, T. M. Keane, & P. A. Resick (Eds.),
Handbook of PTSD: Science and practice (pp. 482-501). New York, NY: Guilford Press.
 RESOURCES

Anxiety and Depression Association of America

(http://www.adaa.org/).
This organization maintains a website specifically devoted to issues related to anxiety disorders,
depression, PTSD, and obsessive-compulsive disorder (OCD). 8701 Georgia Avenue, Suite 412,
Silver Spring, MD 20910, 240-485-1001.
Freedom From Fear
(http://www.freedomfromfear.org).
This website provides articles, a library, and individuals’ blogs related to anxiety, PTSD, OCD, and
depression. 308 Seaview Avenue, Staten Island, NY 10305, 718-351-1717.
Gateway to Post Traumatic Stress Disorder Information
(http://www.ptsdinfo.org/).
This website is a public service of the Dart Foundation and provides links to the websites of four
national and international organizations that help, with articles, references, web links, mini-courses,
800 phone access, and e-mail pen-pal resources.
Gift From Within: An International Nonprofit Organization for Survivors of Trauma and Victimization
(http://www.giftfromwithin.org/).
This website maintains links to a variety of articles, as well as discussion boards and survivor
stories. 16 Cobb Hill Road, Camden, ME 04843, 207-236-2818.
International Society for Traumatic Stress Studies
(http://www.istss.org).
The mission of ISTSS is to prevent traumatic exposure, ameliorate its consequences, advance and
exchange knowledge about traumatic stress, and advocate for the field of traumatic stress studies
and for those experiencing trauma exposure. One Parkview Plaza, Suite 800, Oakbrook Terrace, IL
60181, 847-686-2251.
MedlinePlus
(http://www.nlm.nih.gov/medlineplus/posttraumaticstressdisorder.html).
This website contains a large number of links to a wide variety of PTSD-related information.
National Alliance on Mental Illness (NAMI)
(http://www.nami.org).
The NAMI website provides information on a wide variety of mental health problems, including
PTSD. 3803 N. Fairfax Drive, Suite 100, Arlington, VA 22203, 703-524-7600. Helpline:
800-950-NAMI.

31
 Resources—
32 Understanding Posttraumatic Stress Disorder: From Assessment to Treatment

The National Child Traumatic Stress Network (NCTSN)

(http://www.nctsnet.org).
The mission of the NCTSN is to raise the standard of care and improve access to services for trauma-
tized children, their families, and communities throughout the United States. The website provides
useful educational and awareness materials, treatment protocols, and other national resources.
National Institute of Mental Health
(http://www.nimh.nih.gov/health/topics/post-traumatic-stress-disorder-ptsd/index.shtml).
This website provides links to fact sheets as well as new research results regarding PTSD.
PTSD Alliance
(http://www.ptsdalliance.org/).
This alliance is an association of advocacy and professional organizations across the healthcare
spec- trum, serving individuals experiencing PTSD. It provides comprehensive education,
resources, and referral contacts for individuals or family members to call for help. 888-436-6306.
Rape, Abuse & Incest National Network (RAINN)
(http://www.rainn.org).
This website provides information on sexual assault-related issues. 800-656-4673.
The Trauma Center at the Justice Resource Institute
(http://www.traumacenter.org).
The Trauma Center offers clinical services, provides training and consultation on assessment and treat-
ment to professionals, and conducts ongoing research on the effects of trauma on children and adults
around the world. The website offers a wealth of information about trauma and trauma treatment.
U. S. Department of Veterans Affairs, National Center for PTSD
(http://www.ptsd.va.gov).
This website contains a great deal of PTSD-specific information, including helpful fact sheets for
clients and their families as well as healthcare practitioners.
Wounded Warrior Project
(https://www.woundedwarriorproject.org/).
This website provides a multitude of resources for veterans and their families. Under the program link,
the combat stress recovery program specifically provides information and resources regarding PTSD.
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