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Posttraumatic stress disorder

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Updated 2023 VA/DoD guidelines for the diagnosis and management of posttraumatic stress disorder.

Background

Overview

Definition
PTSD is a mental disorder resulting from exposure to a traumatic experience, which is typically characterized by intrusive, involuntary, and/or distressing recollection or re-experience of the traumatic events.
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Pathophysiology
PTSD is caused by traumatic exposure to death, injury, sexual assault, torture, or bodily disfigurement.
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Epidemiology
In the US, the estimated prevalence of PTSD, based on the Same Event definition of DSM-V for lifetime, past 12 months, and past 6 months, is 8.3%, 4.7%, and 3.8%, respectively.
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Disease course
The psychological impact of trauma leads to abnormalities in fear learning, threat detection, executive function, emotion regulation, and contextual processing. These neuroendocrine changes are linked to altered activity in the amygdala. PTSD is associated with mood, anxiety, substance abuse disorders, or suicidal ideation leading to serious disability, medical illness, and premature death. The relative risk of suicidal ideation in PTSD is similar to the relative risk of generalized anxiety disorder or alcohol dependence; however, is lower than that of depression.
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Guidelines

Key sources

The following summarized guidelines for the evaluation and management of posttraumatic stress disorder are prepared by our editorial team based on guidelines from the Canadian Expert Group on Cannabinoids Use in Chronic Pain (CCP-CEG 2023), the United States Department of Defense (DoD/VA 2023), the World Health Organization (WHO 2023), the American Psychiatric Association (APA 2019), the Ontario Neurotrauma Foundation (ONF ...
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Screening and diagnosis

Indications for screening: as per DoD/VA 2023 guidelines, consider using the Primary Care PTSD Screen for DSM-5 for screening for PTSD.
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  • Diagnosis

Medical management

General principles
As per DoD/VA 2023 guidelines:
Offer individual psychotherapy over pharmacologic interventions for the treatment of PTSD.
A
Avoid precluding psychotherapies from the treatment of PTSD in patients with comorbid substance use disorder and/or other disorders.
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  • Antidepressants

  • Antipsychotics

  • Anticonvulsants

  • Alpha-blockers

  • Other medications

  • Combination therapy

Nonpharmacologic interventions

Psychotherapy: as per DoD/VA 2023 guidelines, offer any of the following individual, manualized trauma-focused psychotherapies for the treatment of PTSD:
cognitive processing therapy
eye movement desensitization and reprocessing
prolonged exposure.
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  • Technology-based interventions

  • Alternative and complementary therapies

Therapeutic procedures

Therapies with no evidence for benefit: as per DoD/VA 2023 guidelines, avoid offering electroconvulsive therapy or vagus nerve stimulation for the treatment of PTSD.
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Specific circumstances

Patients after traumatic brain injury: as per ONF 2018 guidelines, assess for symptoms of PTSD in the assessment of common post-concussive mental health symptoms in patients after concussion.
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Preventative measures

Prevention after acute stress: as per DoD/VA 2023 guidelines, insufficient evidence to recommend for or against psychotherapy or pharmacotherapy in the immediate post-trauma period to prevent PTSD in persons exposed to trauma.
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Follow-up and surveillance

Assessment of treatment response: as per DoD/VA 2023 guidelines, consider using a validated instrument, such as the PTSD Checklist for DSM-5, or a structured clinician-administered interview, such as the Clinician-Administered PTSD Scale, to detect changes in symptom severity over time.
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