Clinical Guidelines for

Post-traumatic Stress
Disorder
Mylea Charvat – PTSD Specialist
War Related Illness and Injury Study Center
VA Palo Alto Health Care System
mylea.charvat@va.gov
 Outline
 Epidemiology and Criteria
 Risk Pathways to PTSD
 Gender & Cultural Issues in PTSD
 DoD Guidelines:
 Diagnosis & Assessment
 Pharmacology
 Psychotherapies
 Resources
 DSM-IV Criteria
Person Experiences Traumatic Event
Person Experiences Fear, Helplessness or Horror
The person experiences a combination of the following Sx which are still present > 4
weeks following the TE, last more than one month and cause significant distress
Re-experiencing >1 Avoidance >3 Hyperarousal >2
Intrusive thoughts or Efforts to avoid trauma Difficulty with sleep
memories related thoughts or feelings Irritability and anger
Trauma related dreams Avoidance of people, places Attention and
Acting/feeling as though
or activities that trigger Concentration problems
reminders of trauma
the trauma were Memory loss for all or parts
Hypervigilence
reoccurring of the trauma Exaggerated startle
Emotional distress in Loss of interest in activities reaction
response to triggers Feelings of estrangement
Physical Sx in response from others
to triggers Expectation of foreshortened
future
 Epidemiology of Trauma
Exposure
 Only National Sample (Kessler et al., 1995) of trauma
exposure
 61% of men reported DSM-III TE
 51% of women reported DSM-III TE
 Veteran Data (US DVA, 2003) – surveyed 20,000
Veterans in US
 Combat exposure (41% men/ 12% women)
 36% exposure to dead/dying/wounded
 No MST data were collected
 WWII Veterans reported a 54% exposure rate to combat
compared to 19% for Korea
 Epidemiology of PTSD
 Rates Consistent since DSM-III-R
 Estimates range between 6% and 12% in
general population
 Kessler et al., 1995 - National survey
found PTSD rates of:
 20% for women
 8% for men
 Epidemiology of PTSD in
Veterans
 Study of 2,300 Vietnam Era Veterans
 31% of men met PTSD criteria
 27% of women met PTSD criteria
 Prevalence higher with
 Army service (compared to other branches)
 >12 months service
 Entering service between age of 17 and 19
 (Kulka et al., 1990; Schlenger et al., 1992)
Estimates of TE Exposure &
PTSD prevalence among
OEF/OIF Veterans
100
90
80
70 Criterion A
60 Stressor
50 PTSD Low Est.
40
30 PTSD High Est.
20
10
0
Military Personnel
 Risk Pathways to PTSD
 TEs that involve injury to self or others
 TEs that are more “malicious” and “grotesque”
 Dissociation at the time of the TE
 Lower education levels
 Lower SES
 Minority racial/ethnic status
 Family psychiatric history (esp. childhood abuse)
 Lack of social support
 Feelings of guilt or shame re the TE
 Previous trauma history
 Also small literature indicating prior trauma may inoculate against future
trauma/PTSD
 Gender Issues in PTSD
 Women are at greater risk for PTSD than
men
 When trauma characteristics are more
“equal” (political situations or violent
community) gender differences in PTSD
rates disappear
 Gender Issues in PTSD
 Differences seem to be defined by trauma
characteristics
 Women are more likely to experience sexual assault
and chronic abuse (intimate partner or childhood
sexual abuse)
 VA-DOD Clinical Guidelines
 Recommendations for the performance or
exclusion of specific procedures or
services for specific disease entities
 Derived through a rigorous methodological
approach
 Includes a systematic review of the evidence
to outline recommended practice
 Displayed in the form of a flowchart
algorithm
 Treatment Guidelines
 A potential solution to inefficiency and
variation in care
 A user-friendly format for training and
education on PTSD treatment
 Designed to inform and support clinicians
 Must always be applied in the context of an
individual provider's clinical judgment for the
care of a particular patient
 Development of DoD/VA
Treatment Guidelines
 DoD represented by members of Army, Navy, and Air
Force
 DVA represented by staff of VAMCs, Readjustment
Counseling Service, and the National Center for PTSD
 Disciplines represented include psychiatrists, primary
care physicians, psychologists, nurses, pharmacists,
occupational therapists, social workers, counselors,
chaplains, and administrators
 Scope of DoD Treatment
Guidelines
 Developed to address the full spectrum of traumatic-
stress response
 Acute Stress Response/Combat Stress Response
 Acute Stress Disorder
 PTSD
 Acute PTSD
 Chronic PTSD
 PTSD with co-morbid Major Depression and/or substance abuse
 Complex PTSD
 Negative health behaviors known to adversely affect clinical
outcomes in those with PTSD
 Limitations and Challenges
 Inadequate clinical trials in combined treatments
(such as psychotherapy and pharmacotherapy)
versus single treatment approaches.
 Not clear whether a treatment effective for
combat Veterans with PTSD will be equally
useful for survivors of another trauma, such as
recent sexual assault.
 Inadequate research on treatment of PTSD in
patients with dual diagnosis (i.e. substance
abuse/MDD)
 Diagnosis & Assessment of PTSD
 All new patients should be screened for symptoms of PTSD
 Thereafter, annually or more frequently if suspicion, recent exposure,
history of PTSD
 Paper-and-pencil or computer-based screening tools should be
used
 Notes importance of
 Balancing efficacy with practical concerns (staffing, time constraints,
current clinical practices)
 Avoiding stigmatization and adverse occupational effects of positive
screens
 Individuals with positive screens should receive more detailed
assessment of their symptoms (i.e. CAPS, MMPI)
 PTSD Checklist (PCL-M or PCL-C)

 17 item self report questionnaire

 In the public domain
 Available in CPRS or pen and paper
 Short and easy to score/interpret
 Total Severity Score correlation with the
CAPS = .94
 For women Veterans utilize the PCL-C
 Pharmacology Guidelines
 Monotherapy
 Strongly recommend SSRIs
 2nd line: TCAs and MAOIs
 Consider trial of at least 12 weeks before changing medications
 Consider 2nd generation (e.g., trazodone, buproprion)
 Augmented therapy for targeted symptoms
 Consider prazosin for nightmares and other PTSD symptoms
 Recommend medication compliance assessment at each visit
 Recommend against…
 Benzodiazepines to manage core symptoms of PTSD
 Typical antipsychotics in management of PTSD
 Psychotherapies
 Significant benefit – Strongly recommended
 Cognitive Therapy
 Exposure Therapy
 Stress Inoculation Training
 Eye Movement Desensitization Reprocessing (EMDR)
 Some benefit –
 Imagery rehearsal therapy
 Psychodynamic therapy
 Patient education (recommended for all patients)
 Cognitive Therapy
 Systematic approach to challenging
negative trauma-related beliefs (e.g., “I
should have prevented it”)
 Educate about role of beliefs in causing
distress
 Identify distressing beliefs
 Discuss, review evidence, and generate
alternative beliefs
 Rehearse revised beliefs
 Exposure Therapy
 Imaginal exposure = repeated retelling of
trauma story with emotional activation
 In vivo exposure = assignments to
confront feared stimuli in environment
 Prolonged Exposure
 Multiple repetitions via homework
 Listening to cassette
 Writing
 Intended to help survivors habituate to stimuli
 Stress Inoculation
 Focus on management of symptoms
 Coping skills training
 Education
 Muscular relaxation training
 Breathing retraining (slow abdominal breathing)
 Assertiveness
 Covert modeling
 Role playing
 Thought stopping
 Positive thinking and self-talk
 EMDR
 Identify
 Disturbing image (worst part of event)
 Associated body sensation
 Negative self-referring cognition (what learned from event)
 Positive self-referring cognition
 Hold image/sensation/negative cognition in mind while
tracking clinician’s moving finger for 20 seconds
 Describe changes, new associations
 Repeat tracking episodes and reinforce positive
cognition
 Imagery Rehearsal Therapy
 Select a memory or nightmare
 “Change the memory any way you wish”
 Patient writes down the “new version”
 Rehearse daily
 Includes education, tools for controlling
imagery
 Psychodynamic Therapy
 Re-engage normal adaptation by addressing
unconscious to make it conscious.
 Deals with fears, fantasies, wishes, and
defenses.
 Managing transference and counter-
transference issues with an emphasis on the
importance of the therapeutic relationship.
 Strength of evidence: few clinical trials exist
overall. Most evidence is in clinical case studies
 Patient Education
 Recommended for all Veterans diagnosed with
PTSD
 Usually conducted as a once a week group with
a different topic each week
 Topics include (but are not limited to):
 What is PTSD?
 Types of symptoms
 Sleep and PTSD
 Anger and PTSD
 Evaluation of Treatment
Efficacy
 Regular use of self-administered
checklists
 Follow up status should be routinely
monitored at least every 3 months, using
interview and questionnaire methods
Trauma Assessment in Primary
Care
 If presumed PTSD or positive PTSD screen, then
conduct or refer for in-depth PTSD Assessment
 Recommend use of self-report measures (PCL-M, PCL-
C, Mississippi-M, Mississippi-C)
 PTSD Evaluation in Primary Care
 If H/O Trauma - Recommend assessment of:
 PTSD Symptoms
 Dangerousness to self or others
 Family and social environment
 Ongoing health risks
 Medical/psychiatric co-morbidities
 Thorough history and physical
 Appropriate lab evaluation
 Radiological assessment
 Level of functioning
 Risk factors for development of ASD/PTSD
 Substance use
 Primary Care Treatment
Recommendations
 Formulate presumptive diagnosis
 Consider initiating treatment or referral
 Treat complicating problems
 Pain, insomnia, anxiety, depression
 If complicated, refer to mental health
 Consult with MH
 Stay involved in treatment
 Take leadership in convening collaborative team
 Primary Care Encouraged to:
 Routinely provide:
 Early recognition of PTSD
 Supportive counseling
 PTSD-related education
 PTSD symptoms
 Other traumatic stress problems/consequences
 Practical ways of coping with symptoms
 Processes of recovery
 Nature of treatments
 Regular follow-up and monitoring of symptoms
 Guideline Concordance
 Assessment
 Complete PTSD & MST Clinical Reminders as part of routine patient
care
 Assess war-zone experiences systematically
 Screen for trauma history - PTSD
 Use standardized initial and follow-up assessments (i.e. PCL) to monitor
progress and evaluate treatment
 Treatment
 Increase use of “strongly recommended” treatments
 Combined prolonged exposure and cognitive therapy
 Stress inoculation training
 EMDR
 Contact NCPTSD Education Division (josef.ruzek@va.gov ) or
War Related Illness & Injury Study Center (mylea.charvat@va.gov)
 Resources
 List of all inpatient and outpatient PTSD
treatment programs:
vaww.nepec.mentalhealth.va.gov/PTSD

 National Center for PTSD Information

Center:

http://www.ncptsd.va.gov/ncmain/informati
on