Internet Mental Health

POSTTRAUMATIC STRESS DISORDER






Expanded Quality of Life Scale For Posttraumatic Stress Disorder

Internet Mental Health Quality of Life Scale

Big 5 Factors Of Mental Illness And Code For This Disorder
(The "6th Big Factor" of Mental Health, "Physical Health", Is Coded Normal or Green)

  • After exposure to a severe trauma, developed at least 1 month of specific stress symptoms (e.g., intrusion symptoms, negative mood, dissociative symptoms, avoidance symptoms, arousal symptoms).

  • The symptoms of this disorder are identical to that of Acute Stress Disorder - except this disorder lasts 1 month or longer.

  • Causes clinically significant distress or impairment.

  • Is not merely an exacerbation of a preexisting mental disorder.

  • Is not due to a medical or substance use disorder.

Prediction

    Half recover within 3 months but a small minority go on for years.

Problems

Occupational-Economic Problems:

  • Causes significant impairment in academic, occupational and/or social functioning

  • Course is fluctuating but majority recover; in a small minority, this disorder lasts many years

  • Can severely impair work and social functioning

Critical, Quarrelsome (Antagonism):

  • Irritable behavior and angry outbursts (with little or no provocation)

Impulsive, Disorderly (Disinhibition):

  • Reckless or self-destructive behavior

  • Increased rate of Substance-Related Disorders

Dissociative Symptoms (Impaired Intellect):

  • Flashbacks: episodes in which the individual feels or acts as if the traumatic event(s) were recurring

  • Disorientation: dissociative symptoms may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings

Reserved, Quiet (Detachment):

  • Social withdrawal

Distressed, Easily Upset (Negative Emotion):

  • Intrusion symptoms: recurrent, involuntary, and intrusive distressing memories, dreams, and flashbacks of the traumatic event(s)

  • Negative mood: persistent inability to experience positive emotions

  • Avoidance symptoms: efforts to avoid distressing memories or external reminders that arouse distressing memories

  • Arousal symptoms: sleep disturbance, irritability, hypervigilance, problems with concentration, exaggerated startle response

  • Increased rates of Major Depressive Disorder, all of the other adult Anxiety Disorders, and Bipolar Disorder. These disorders can either precede, follow, or emerge concurrently with the onset of PTSD

Medical:
  • Usually a state of autonomic hyperarousal with hypervigilance, an enhanced startle reaction, and insomnia; increased rates of somatic complaints
  • Increased rate of Substance-Related Disorders (as an attempt at self-medicating the anxiety)


Explanation Of Terms And Symbols

Internet Mental Health Quality of Life Scale

Fear, Generalized Anxiety, Phobia, Panic, Obsession, and Compulsion

Fearful avoidance is part of our instinctual "flight" response to adversity.

Our ancestors learned to fear dangerous things (e.g., snakes), and this harm avoidance saved their lives.

However, fear can spiral out of control. For example, an individual can develop a phobia to snakes in which the fear becomes excessive. The individual may then panic if exposed to snakes. This phobia can develop into an obsession in which the individual spends much of the time thinking about snakes, and how to avoid them. The obsession can develop into a compulsion in which the individual spends much of the time doing superstitious, compulsive, ritual behaviors aimed at avoiding snakes.

There are stages in the escalation of fear:

  • Normal Fear:
    Fear is normal if it is in proportion to the actual danger posed by the specific object or situation, and this fear doesn't cause significant distress or disability.

  • Generalized Anxiety:
    Fear can become excessive, and generalized with excessive anxiety and worry about a number of objects or situations. This anxiety is often associated with avoidance of the feared objects or situations and irritability. Generalized anxiety, especially about distressing memories of the traumatic event, can be very marked in posttraumatic stress disorder.

  • Phobia:
    Fear can become excessive, and specifically attached to specific objects or situations (e.g., fear of flying). This phobic fear is out of proportion to the actual danger posed by these feared objects or situations, and the individual desperately tries to avoid whatever triggers the phobia. This phobic fear causes significant distress or disability. Individuals with posttraumatic stress disorder can develop intense phobic reactions to reminders of the traumatic event.

  • Panic:
    Phobic individuals can develop a full-blown panic attack if exposed to whatever triggers their phobia. In panic disorder, individuals experience panic attacks that occur spontaneously, and that are not triggered by any phobic stimulus. Individuals with posttraumatic stress disorder commonly experience panic attacks in the initial month after trauma exposure that may be triggered by reminders of the traumatic event, or these panic attacks may occur spontaneously.

  • Obsession:
    If the individual develops persistent, unwanted thoughts about the phobia; this is defined as an obsession. An obsession is a fear-provoking intrusive thought. The recurrent, involuntary, and intrusive distressing memories of traumatic event(s) seen in posttraumatic stress disorder could be argued to be obsessions. (Obsessions are defined as: "Recurrent and persistent thoughts, urges, or images that are experienced as intrustive and unwanted and that in most individuals cause marked anxiety or distress. The individual attempts to ignore or suppress such thoughts, urges, or images, or to neutralize them with some other thought or action.") For example, individuals - especially children - may become preoccupied with reminders of their trauma. For example, young children bitten by a dog may become obsessed with dogs and talk about them constantly, and avoid going outside because of their phobic fear of dogs.

  • Compulsion:
    A compulsion is a ritual an individual develops to combat an obsession. Thus compulsions are fear-relieving avoidance behaviors. The individual feels driven to perform these compulsions. The compulsive substance abuse, gambling or impulsive behavior individuals use to relieve their symptoms of acute stress disorder come close to being compulsive.


Back to top


Click Here For Free Diagnosis

Limitations of Self-Diagnosis

Self-diagnosis of this disorder is often inaccurate. Accurate diagnosis of this disorder requires assessment by a qualified practitioner trained in psychiatric diagnosis and evidence-based treatment.

However, if no such professional is available, our free computerized diagnosis is usually accurate when completed by an informant who knows the patient well. Computerized diagnosis is less accurate when done by patients (because they often lack insight).

Example Of Our Computer Generated Diagnostic Assessment

Posttraumatic Stress Disorder 309.81

This diagnosis is based on the following findings:
  • Exposed to very upsetting traumatic event(s)
  • This distress or disability was not due to to a substance or another medical condition
  • Duration of the disturbance was more than 1 month
  • This traumatic event caused clinically significant distress or disability (still present)
  • Recurrent, involuntary, and intrusive distressing memories of the traumatic event (still present)
  • Recurrent distressing dreams about this traumatic event (still present)
  • Dissociative reactions (e.g., flashbacks) of the traumatic event recurring (still present)
  • Intense or prolonged psychological distress when reminded of this traumatic event (still present)
  • Marked physiological reactions when reminded of this traumatic event (still present)
  • Tried hard to avoid thinking about this traumatic event (still present)
  • Tried hard to avoid external reminders of this traumatic event (still present)
  • Inability to remember an important aspect of the traumatic event(s) (still present)
  • Exaggerated negative beliefs after this traumatic event (still present)
  • Incorrectly blames herself or others about the cause or consequences of the traumatic event (still present)
  • Persistent negative emotional state after this traumatic event (still present)
  • Markedly diminished interest in significant activities after this traumatic event (still present)
  • Feelings of detachment or estrangement from others after this traumatic event (still present)
  • Persistent inability to experience positive emotions after this traumatic event (still present)
  • Irritable behavior and angry outbursts (with little or no provocation) after this traumatic event (still present)
  • Reckless or self-destructive behavior after the traumatic event (still present)
  • More hypervigilant after this traumatic event (still present)
  • Exaggerated startle response after this traumatic event (still present)
  • More problems with concentration after this traumatic event (still present)
  • More difficulty sleeping after this traumatic event (still present)

TREATMENT GOALS:

  • Goal: prevent the recurrent, intrusive, distressing recollections of the traumatic event
  • Goal: prevent the recurrent distressing dreams about the traumatic event
  • Goal: prevent acting or feeling as if the traumatic event were recurring
  • Goal: prevent having intense psychological distress when reminded of the traumatic event(s)
  • Goal: prevent having intense physiological distress when reminded of the traumatic event
  • Goal: overcome trying to avoid thinking about the traumatic event
  • Goal: overcome avoiding activities associated with the traumatic event
  • Goal: overcome inability to remember an important aspect of the traumatic event(s)
  • Goal: overcome exaggerated negative beliefs or expectations
  • Goal: prevent incorrectly blaming herself (or others) for the traumatic event(s)
  • Goal: overcome persistent negative emotional state
  • Goal: increase interest or participation in significant activities
  • Goal: overcome feelings of detachment or estrangement from others
  • Goal: overcome inability to experience positive emotions
  • Goal: overcome irritability or outbursts of anger
  • Goal: prevent reckless or self-destructive behavior/li>
  • Goal: overcome hypervigilance
  • Goal: overcome exaggerated startle response
  • Goal: overcome problems with concentration
  • Goal: overcome difficulty sleeping

Back to top


Posttraumatic Stress Disorder F43.1 - ICD10 Description, World Health Organization

Arises as a delayed or protracted response to a stressful event or situation (of either brief or long duration) of an exceptionally threatening or catastrophic nature, which is likely to cause pervasive distress in almost anyone. Predisposing factors, such as personality traits (e.g. compulsive, asthenic) or previous history of neurotic illness, may lower the threshold for the development of the syndrome or aggravate its course, but they are neither necessary nor sufficient to explain its occurrence. Typical features include episodes of repeated reliving of the trauma in intrusive memories ("flashbacks"), dreams or nightmares, occurring against the persisting background of a sense of "numbness" and emotional blunting, detachment from other people, unresponsiveness to surroundings, anhedonia, and avoidance of activities and situations reminiscent of the trauma. There is usually a state of autonomic hyperarousal with hypervigilance, an enhanced startle reaction, and insomnia. Anxiety and depression are commonly associated with the above symptoms and signs, and suicidal ideation is not infrequent. The onset follows the trauma with a latency period that may range from a few weeks to months. The course is fluctuating but recovery can be expected in the majority of cases. In a small proportion of cases the condition may follow a chronic course over many years, with eventual transition to an enduring personality change (F62.0).

Enduring Personality Change After Catastrophic Experience F62.0 - ICD10 Description, World Health Organization
Enduring personality change, present for at least two years, following exposure to catastrophic stress. The stress must be so extreme that it is not necessary to consider personal vulnerability in order to explain its profound effect on the personality. The disorder is characterized by a hostile or distrustful attitude toward the world, social withdrawal, feelings of emptiness or hopelessness, a chronic feeling of "being on edge" as if constantly threatened, and estrangement. Post-traumatic stress disorder (F43.1) may precede this type of personality change.

Posttraumatic Stress Disorder (Age 7 And Older) - Diagnostic Criteria, American Psychiatric Association

An individual (aged 7 or older) diagnosed with post-traumatic stress disorder needs to meet all of the following criteria:

  • Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways:

    • Directly experiencing the traumatic event(s).

    • Witnessing, in person, the event(s) as it occurred to others.

    • Learning that the traumatic event(s) occurred to a close family member or close friend. In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental.

    • Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders collecting human remains; police officers repeatedly exposed to details of child abuse). Note: This does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work related.

  • Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred:.

    • Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). Note: In children older than 6 years, repetitive play may occur in which themes or aspects of the traumatic event(s) are expressed.

    • Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s). Note: In children, there may be frightening dreams without recognizable content.

    • Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings.) Note: In children, trauma-specific reenactment may occur in play.

      Ask: "Are you having 'flashbacks,' that is, do you suddenly act or feel as if a stressful experience from the past is happening all over again (for example, you reexperience parts of a stressful experience by seeing, hearing, smelling, or physically feeling parts of the experience)?"

    • Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).

      Ask: "Do you feel very emotionally upset when something reminds you of a stressful experience?"

    • Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).

  • Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic event(s) occurred, as experienced by one or both of the following:

    • Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).

      Ask: "Do you try to avoid thoughts, feelings, or physical sensations that remind you of a stressful experience?"

    • Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).

  • Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:

    • Inability to remember an important aspect of the traumatic event(s) (typically due to dissociative amnesia and not to other factors such as head injury, alcohol, or drugs).

    • Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g., "I am bad," "No one can be trusted," "The world is completely dangerous," "My whole nervous system is permanently ruined").

    • Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame himself/herself or others.

      Ask: "Do you think that a stressful event happened because you or someone else (who didn't directly harm you) did something wrong or didn't do everything possible to prevent it, or because of something about you?"

    • Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame).

      Ask: "Are you having a very negative emotional state (for example, you are experiencing lots of fear, anger, guilt, shame, or horror) after a stressful experience?"

    • Markedly diminished interest or participation in significant activities.

      Ask: "Are you losing interest in activities you used to enjoy before having a stressful experience?"

    • Feelings of detachment or estrangement from others.

    • Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings).

  • Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (o more) of the following:

    • Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects.

      Ask: "Are you extremely irritable or angry to the point where you yell at other people, get into fights, or destroy things?"

    • Reckless or self-destructive behavior.

    • Hypervigilance.

      Ask: "Are you 'super alert,' on guard, or constantly on the lookout for danger?"

    • Exaggerated startle responose.

      Ask: "Do you feel jumpy or easily startled when you hear an unexpected noise?"

    • Problems with concentration.

    • Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).

  • Duration of the disturbance is more than 1 month.

  • The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

  • The disturbance is not attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition.

  • ("Ask" questions are not part of the DSM-5. Instead, they are inserted from the Severity of Posttraumatic Symptoms - Adult scale.

Posttraumatic Stress Disorder (Age 6 And Younger) - Diagnostic Criteria, American Psychiatric Association

A child (6 or younger) diagnosed with post-traumatic stress disorder needs to meet all of the following criteria:

  • Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways:

    • Directly experiencing the traumatic event(s).

    • Witnessing, in person, the event(s) as it occurred to others, especially primary caregivers. Note: Witnessing does not include events that are witnessed only in electronic media, television, movies, or pictures.

    • Learning that the traumatic event(s) occurred to a parent of caregiving figure.

  • Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred:.

    • Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). Note: Spontaneous and intrusive memories may not necessarily appear distressing and may be expressed as play reenactment.

    • Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s). Note: It may not be possible to ascertain that the frightening content is related to the traumatic event.

    • Dissociative reactions (e.g., flashbacks) in which the child feels or acts as if the traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings.) Such trauma-specific reenactment may occur in play.

    • Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).

    • Marked physiological reactions to reminders of the traumatic event(s).

  • One (or more) of the following symptoms, representing either persistent avoidance of stimuli associated with the traumatic event(s) or negative alterations in cognitions and mood associated with the traumatic event(s), must be present, beginning after the event(s) or worsening after the event(s):

    • Persistent Avoidance of Stimuli

    • Avoidance of or efforts to avoid activities, places, or physical reminders that arouse recollections of the traumatic event(s).

    • Avoidance of or efforts to avoid people, conversations, or interpersonal situations that arouse recollections of the traumatic event(s).

    • Negative Alterations in Cognition

    • Substantially increased frequency of negative emotional states (e.g., fear, horror, anger, guilt, shame, confusion).

    • Markedly diminished interest or participation in significant activities, including constriction of play.

    • Socially withdrawn behavior.

    • Persistent reduction in expression of positive emotions.

  • Alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:

    • Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects (including extreme temper tantrums).

    • Hypervigilance.

    • Exaggerated startle responose.

    • Problems with concentration.

    • Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).

  • The duration of the disturbance is more than 1 month.

  • The disturbance causes clinically significant distress or impairment in relationships with parents, siblings, peers, or other caregivers or with school behavior.

  • The disturbance is not attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition.


Back to top


Diagnostic Features

Posttraumatic Stress Disorder (PTSD) is a condition characterized by intense fear, helplessness, or horror (or disorganized or agitated behavior in children) resulting from exposure to extreme trauma. An arbitary distinction is made between acute stress disorder (in which similar symptoms are present for less than 1 month) and PTSD (where the same symptoms are present for at least 1 month). It is characterized by 3 types of symptoms: re-experiencing (e.g., flashbacks, intrusive images and sensory impressions, dreams/nightmares); avoidance (e.g., avoiding people, situations, or circumstances resembling or associated with the event); and hyperarousal (e.g., hypervigilance for threat, exaggerated startle response, irritability, difficulty concentrating, and sleep problems). These symptoms must cause significant distress or life impairment for a diagnosis to be made.

Complications

Individuals with PTSD may describe painful guilt feelings about surviving when others did not survive or about the things they had to do to survive. Avoidance patterns may interfere with interpersonal relationships and lead to marital conflict, divorce, or loss of job. Auditory hallucinations and paranoid ideation can be present in some severe and chronic cases.

Comorbidity

PTSD often co-occurs with increased rates of Major Depressive Disorder, Substance Use Disorders, Panic Disorder, Agoraphobia, Obsessive-Compulsive Disorder, Generalized Anxiety Disorder, Social Anxiety Disorder, Specific Phobia, and Bipolar Disorder. These disorders can either precede, follow, or emerge concurrently with the onset of PTSD. Chronic PTSD may be associated with increased rates of somatic complaints and general medical conditions.

Associated Laboratory Findings

No laboratory test has been found to be diagnostic of PTSD. However, often individuals with this disorder have increased arousal which may be measured through studies of autonomic functioning (e.g., heart rate, electromyography, sweat gland activity).

Prevalence

In the United States, the lifetime prevalence rate for PTSD is 8%. However, the highest rates (ranging between one-third to more than half of those exposed) is found among survivors of rape, military combat and captivity, and ethnically or politically motivated internment and genocide.

Course

PTSD can occur at any age, including childhood. Symptoms usually begin within the first 3 months after the trauma, although there may be a delay of months, or even years, before symptoms appear. Frequently, the person first has an Acute Stress Disorder in the immediate aftermath of the trauma. The duration of PTSD varies, with complete recovery occurring within 3 months in approximately half of the cases, with many others having persisting symptoms for longer than 12 months after the trauma. In some cases, the course is characterized by waxing and waning of symptoms. Symptom reactivation may occur in response to reminders of the original trauma, life stressors, or new traumatic events.

Outcome

The severity, duration, and proximity of an individual's exposure to the traumatic event are the most important factors affecting the likelihood of developing this disorder. This disorder can develop in individuals without any predisposing conditions, particularly if the stressor is especially extreme.

Familial Pattern

There is evidence of a heritable component to the transmission of PTSD. A history of depression in first-degree relatives has been related to an increased vulnerability to developing PTSD.

Effective Therapies

Individual trauma focused cognitive-behavioural therapy (TFCBT) is effective in the treatment of PTSD. Other non-trauma focused psychological treatments do not reduce PTSD symptoms as significantly. SSRI antidepressant medication is also a first line treatment for PTSD (NNT= 4.8; SSRI response rate= 59.1% vs. placebo response rate= 38.5%). It is not yet known whether combination therapy (TFCBT + SSRI antidepressant medication) is more effective than either treatment used alone. Unfortunately, more than one-third of people with this disorder fail to recover even after many years.

Ineffective therapies

Certain treatments worsen PTSD. Research has shown that compulsory psychological intervention offered to everyone after a trauma (e.g., school tragedy) is harmful and may make PTSD worse. Watchful waiting, with treatment given only to those individuals that develop PTSD, is far more effective than compulsory "Psychological Debriefing" (to "prevent" PTSD) given to every traumatized individual.

Vitamins and dietary supplements are ineffective for this disorder.

A Dangerous Cult


Back to top


Videos

Stories

Rating Scales

Which Behavioral Dimensions Are Involved?

Research has shown that there are 5 major dimensions (the "Big 5 Factors") of personality disorders and other mental disorders. There are two free online personality tests that assess your personality in terms of the "Big 5 dimensions of personality.

This website uses these 5 major dimensions of human behavior to describe all mental disorders. (This website adds one more dimension, "Physical Health", but our discussion will focus on the first 5 major dimensions.)

These 5 major dimensions of human behavior seem to represent 5 major dimensions whereby our early ancestors chose their hunting companions or spouse. To maximize their chance for survival, our ancestors wanted companions who were agreeable, conscientious, intelligent, enthusiastic, and calm.

    Which Dimensions of Human Behavior are Impaired in Posttraumatic Stress Disorder?

    THE POSITIVE SIDE OF THE "BIG 5" PERSONALITY DIMENSIONS THE NEGATIVE SIDE OF THE "BIG 5" PERSONALITY DIMENSIONS DESCRIPTION (Where red = this disorder)
    Agreeableness Antagonism       Sympathetic, Kind vs. Critical, Quarrelsome
    Conscientiousness Disinhibition       Industrious, Orderly vs. Impulsive, Disorderly
    Openness To Experience Impaired Intellect       Open-Minded, Creative vs. Cognitive Impairment
    Sociability (Extraversion) Detachment       Enthusiastic, Assertive vs. Reserved, Quiet
    Emotional Stability Negative Emotion       Calm, Emotionally Stable vs. Distressed, Easily Upset

The 5 Major Dimensions of Mental Illness

Our website uses the "Big 5 Factors" of personality as major dimensions of mental illness. Each of these 5 dimensions has a healthy side and an unhealthy side. The Big 5 Factors are: Agreeableness, Conscientiousness, Openness to Experience, Sociability (Extraversion), and Emotional Stability. Our website adds an additional factor, Physical Health. However, our discussion will primarily focus on the traditional "Big 5 Factors".



The Following Pictures Are of The International Space Station

AGREEABLENESS VS. ANTAGONISM
.
Agreeableness (Sympathetic, Kind)
.
Description: Agreeableness is synonymous with compassion and politeness; whereas Antagonism is synonymous with competition and aggression. Compassion reflects empathy, sympathy, and caring for others. Politeness reflects respect for others’ needs and desires and a tendency to refrain from aggression. The Agreeableness dimension measures the behaviors that are central to the concept of LOVE and JUSTICE.
Descriptors: Compassionate, polite, kind, sympathetic, appreciative, affectionate, soft-hearted, warm, generous, trusting, helpful, forgiving, pleasant, good-natured, friendly, cooperative, gentle, unselfish, praising, sensitive.
MRI Research*: Agreeableness was associated with increased volume in regions that process information about the intentions and mental states of other individuals.
"I am helpful and unselfish with others."
"I have a forgiving nature."
"I am generally trusting."
"I am considerate and kind to almost everyone."
"I like to cooperate with others."
"I don't find fault with others."
"I don't start quarrels with others."
"I am not cold and aloof."
"I am not rude to others."
"I feel other's emotions."
"I inquire about others' well-being."
"I sympathize with others' feelings."
"I take an interest in other people's lives."
"I like to do things for others."
"I respect authority."
"I hate to seem pushy."
"I avoid imposing my will on others."
"I rarely put people under pressure."
.
Antagonism (Critical, Quarrelsome)
.
* Callousness:
"It's no big deal if I hurt other people's feelings."
"Being rude and unfriendly is just a part of who I am."
"I often get into physical fights."
"I enjoy making people in control look stupid."
"I am not interested in other people's problems."
"I can't be bothered with other's needs."
"I am indifferent to the feelings of others."
"I don't have a soft side."
"I take no time for others."
.
* Deceitfulness:
"I don't hesitate to cheat if it gets me ahead."
"Lying comes easily to me."
"I use people to get what I want."
"People don't realize that I'm flattering them to get something."
.
* Manipulativeness:
"I use people to get what I want."
"It is easy for me to take advantage of others."
"I'm good at conning people."
"I am out for my own personal gain."
.
* Grandiosity:
"I'm better than almost everyone else."
"I often have to deal with people who are less important than me."
"To be honest, I'm just more important than other people."
"I deserve special treatment."
.
* Suspiciousness:
"It seems like I'm always getting a “raw deal” from others."
"I suspect that even my so-called 'friends' betray me a lot."
"Others would take advantage of me if they could."
"Plenty of people are out to get me."
"I'm always on my guard for someone trying to trick or harm me."
.
* Hostility:
"I am easily angered."
"I get irritated easily by all sorts of things."
"I am usually pretty hostile."
"I always make sure I get back at people who wrong me."
"I resent being told what to do, even by people in charge."
"I insult people."
"I seek conflict."
"I love a good fight."
.
("Agreeableness vs. Antagonism" modified from "PID-5" by Kreuger RF, Derringer J, Markon KE, Watson D, Skodol AE and Between facets and domains: 10 aspects of the Big Five)
*MRI Research: Testing predictions from personality neuroscience. Brain structure and the big five.




CONSCIENTIOUSNESS VS. DISINHIBITION
.
Conscientiousness (Industrious, Orderly)
.
Description: Conscientiousness is synonymous with being industrious and orderly; whereas Disinhibition is synonymous with being impulsive and disorderly. The Conscientiousness dimension measures the behaviors that are central to the concept of SELF-CONTROL.
Descriptors: Self-disciplined, achievement-oriented, industrious, competent, reliable, responsible, orderly, deliberate, decisive
MRI Research*: Conscientiousness was associated with increased volume in the lateral prefrontal cortex, a region involved in planning and the voluntary control of behavior.
"I do a thorough job. I want everything to be 'just right'. I want every detail taken care of."
"I am careful."
"I am a reliable hard-worker."
"I am organized. I follow a schedule and always know what I am doing."
"I like order. I keep things tidy."
"I see that rules are observed."
"I do things efficiently. I get things done quickly."
"I carry out my plans and finish what I start."
"I am not easily distracted."
.
Rigid Perfectionism (Excessive Conscientiousness)
.
"Even though it drives other people crazy, I insist on absolute perfection in everything I do."
"I simply won't put up with things being out of their proper places."
"People complain about my need to have everything all arranged."
"People tell me that I focus too much on minor details."
"I have a strict way of doing things."
"I postpone decisions."
.
Disinhibition (Impulsive, Disorderly)
.
* Irresponsibility:
"I've skipped town to avoid responsibilities."
"I just skip appointments or meetings if I'm not in the mood."
"I'm often pretty careless with my own and others' things."
"Others see me as irresponsible."
"I make promises that I don't really intend to keep."
"I often forget to pay my bills."
.
* Impulsivity:
"I usually do things on impulse without thinking about what might happen as a result."
"Even though I know better, I can't stop making rash decisions."
"I feel like I act totally on impulse."
"I'm not good at planning ahead."
.
* Distractibility:
"I can't focus on things for very long."
"I am easily distracted."
"I have trouble pursuing specific goals even for short periods of time."
"I can't achieve goals because other things capture my attention."
"I often make mistakes because I don't pay close attention."
"I waste my time ."
"I find it difficult to get down to work."
"I mess things up."
"I don't put my mind on the task at hand."
.
* Reckless Risk Taking:
"I like to take risks."
"I have no limits when it comes to doing dangerous things."
"People would describe me as reckless."
"I don't think about getting hurt when I'm doing things that might be dangerous."
.
* Hyperactivity:
"I move excessively (e.g., can't sit still; restless; always on the go)."
"I'm starting lots more projects than usual or doing more risky things than usual."
.
* Over-Talkativeness:
"I talk excessively (e.g., I butt into conversations; I complete people's sentences)."
"Often I talk constantly and cannot be interrupted."
.
* Elation:
"I feel much more happy, cheerful, or self-confident than usual."
"I'm sleeping a lot less than usual, but I still have a lot of energy."
.
("Conscientiousness vs. Disinhibition" modified from "PID-5" by Kreuger RF, Derringer J, Markon KE, Watson D, Skodol AE and Between facets and domains: 10 aspects of the Big Five)
*MRI Research: Testing predictions from personality neuroscience. Brain structure and the big five.




OPENNESS TO EXPERIENCE vs. IMPAIRED INTELLECT
.
Open To Experience (Open-Minded, Creative)
.
Description: Open to Experience is synonymous with being open-minded and creative; whereas Closed to Experience is synonymous with being closed-minded and uncreative. The Openness to Experience dimension measures the behaviors that are central to the concept of WISDOM. Open-minded people ask "why?", are willing to challenge something that doesn't seem right, to listen to other people's opinions, and to be ever-ready to accept new truths, if the evidence is there. They are creative, flexible, and holistic in their thinking. They never stop questioning.
Descriptors: Wide interests, imaginative, intelligent, original, insightful, curious, sophisticated, artistic, clever, inventive, sharp-witted, wise
MRI Research*: Openness To Experience did not have any significant correlation with the volume of any brain structures. (This could suggest that "Openness To Experience", as defined here, is more a function of culture rather than of brain neurobiology.)
Example: This video shows how we see what we want to see. What we pay attention to (or what we believe about the world) blinds us to reality. (Exit YouTube after first video.)
"I am original, and come up with new ideas."
"I am curious about many different things."
"I am quick to understand things."
"I can handle a lot of information."
"I like to solve complex problems."
"I have a rich vocabulary."
"I think quickly and formulate ideas clearly."
"I enjoy the beauty of nature."
"I believe in the importance of art."
"I love to reflect on things."
"I get deeply immersed in music."
"I see beauty in things that others might not notice."
"I need a creative outlet."
.
Closed To Experience (Closed-Minded, Uncreative)
.
"I prefer work that is routine."
"I have difficulty understanding abstract ideas."
"I avoid philosophical discussions."
"I avoid difficult reading material."
"I learn things slowly."
"I have few artistic interests."
"I seldom notice the emotional aspects of paintings and pictures."
"I do not like poetry."
"I seldom get lost in thought."
"I seldom daydream."
.
Cognitive Impairment
.
* Memory Impairment:
"I have difficulty learning new things, or remembering things that happened a few days ago."
"I often forget a conversation I had the day before."
"I often forget to take my medications, or to keep my appointments."
.
.
* Impaired Reasoning or Problem-Solving:
"My judgment, planning, or problem-solving isn't good."
"I lack creativity or curiosity."
.
Psychoticism
.
* Eccentricity:
"I often have thoughts that make sense to me but that other people say are strange."
"Others seem to think I'm quite odd or unusual."
"My thoughts are strange and unpredictable."
"My thoughts often don’t make sense to others."
"Other people seem to think my behavior is weird."
"I have several habits that others find eccentric or strange."
"My thoughts often go off in odd or unusual directions."
.
* Unusual Beliefs and Experiences:
"I often have unusual experiences, such as sensing the presence of someone who isn't actually there."
"I've had some really weird experiences that are very difficult to explain."
"I have seen things that weren’t really there."
"I have some unusual abilities, like sometimes knowing exactly what someone is thinking."
"I sometimes have heard things that others couldn’t hear."
"Sometimes I can influence other people just by sending my thoughts to them."
"I often see unusual connections between things that most people miss."
.
* Perceptual Dysregulation:
"Things around me often feel unreal, or more real than usual."
"Sometimes I get this weird feeling that parts of my body feel like they're dead or not really me."
"It's weird, but sometimes ordinary objects seem to be a different shape than usual."
"Sometimes I feel 'controlled' by thoughts that belong to someone else."
"Sometimes I think someone else is removing thoughts from my head."
"I have periods in which I feel disconnected from the world or from myself."
"I can have trouble telling the difference between dreams and waking life."
"I often 'zone out' and then suddenly come to and realize that a lot of time has passed."
"Sometimes when I look at a familiar object, it's somehow like I'm seeing it for the first time."
"People often talk about me doing things I don't remember at all."
"I often can't control what I think about."
"I often see vivid dream-like images when I’m falling asleep or waking up."
.
("OPENNESS TO EXPERIENCE vs. BEING CLOSED TO EXPERIENCE" modified from "PID-5" by Kreuger RF, Derringer J, Markon KE, Watson D, Skodol AE and Between facets and domains: 10 aspects of the Big Five)
*MRI Research: Testing predictions from personality neuroscience. Brain structure and the big five.




SOCIABILITY (EXTRAVERSION) vs. DETACHMENT
.
Sociability (Enthusiastic, Assertive)
.
Description: Sociability is synonymous with being enthusiastic and assertive; whereas Detachment is synonymous with being reserved and quiet. Assertiveness encompasses traits relating to leadership, dominance, and drive. Enthusiasm encompasses both outgoing friendliness or sociability and the tendency to experience and express positive emotion. The Sociability (Extraversion) dimension measures the behaviors that are central to the concept of SOCIABILITY and LEADERSHIP.
Descriptors: Enthusiastic, assertive, sociable, outgoing, talkative, active, energetic, outspoken, dominant, forceful, show-off, spunky, adventurous, noisy, bossy.
MRI Research*: Sociability (extraversion) was associated with increased volume of medial orbitofrontal cortex, a region involved in processing reward information.
"I'm talkative"
"I'm not reserved."
"I'm full of energy."
"I generate a lot of enthusiasm."
"I'm not quiet."
"I have an assertive personality."
"I'm not shy or inhibited."
"I am outgoing and sociable."
"I make friends easily."
"I warm up quickly to others."
"I show my feelings when I'm happy."
"I have a lot of fun."
"I laugh a lot."
"I take charge."
"I have a strong personality."
"I know how to captivate people."
"I see myself as a good leader."
"I can talk others into doing things."
"I am the first to act."
.
Attention Seeking (Excessive Sociability)
.
"I like to draw attention to myself."
"I crave attention."
"I do things to make sure people notice me."
"I do things so that people just have to admire me."
"My behavior is often bold and grabs peoples' attention."
.
Detachment (Reserved, Quiet)
.
* Social Withdrawal:
"I don’t like to get too close to people."
"I don't deal with people unless I have to."
"I'm not interested in making friends."
"I don’t like spending time with others."
"I say as little as possible when dealing with people."
"I keep to myself."
"I am hard to get to know."
"I reveal little about myself."
"I do not have an assertive personality."
"I lack the talent for influencing people."
"I wait for others to lead the way."
"I hold back my opinions."
.
* Intimacy Avoidance:
"I steer clear of romantic relationships."
"I prefer to keep romance out of my life."
"I prefer being alone to having a close romantic partner."
"I'm just not very interested in having sexual relationships."
"II break off relationships if they start to get close."
.
* Anhedonia (Lack of Pleasure):
"I often feel like nothing I do really matters."
"I almost never enjoy life."
"Nothing seems to make me feel good."
"Nothing seems to interest me very much."
"I almost never feel happy about my day-to-day activities."
"I rarely get enthusiastic about anything."
"I don't get as much pleasure out of things as others seem to."
.
* Restricted Affectivity:
"I don't show emotions strongly."
"I don't get emotional."
"I never show emotions to others."
"I don't have very long-lasting emotional reactions to things."
"People tell me it's difficult to know what I'm feeling."
"I am not a very enthusiastic person."
.
("Sociability vs. Detachment" modified from "PID-5" by Kreuger RF, Derringer J, Markon KE, Watson D, Skodol AE and Between facets and domains: 10 aspects of the Big Five)
*MRI Research: Testing predictions from personality neuroscience. Brain structure and the big five.




EMOTIONAL STABILITY VS. NEGATIVE EMOTION
.
Emotional Stability (Calm, Emotionally Stable)
.
Description: Emotional Stability is synonymous with being calm and emotionally stable; whereas Negative Emotion is synonymous with being distressed and easily upset. The Emotional Stability dimension measures the "safety vs. danger" behaviors that are central to the concept of COURAGE.
Descriptors: Stable, calm, relaxed, contented
"I am relaxed, and I handle stress well."
"I am emotionally stable, and not easily upset."
"I remain calm in tense situations."
"I rarely get irritated."
"I keep my emotions under control."
"I rarely lose my composure."
"I am not easily annoyed."
"I seldom feel blue."
"I feel comfortable with myself."
"I rarely feel depressed."
"I am not embarrassed easily."
.
Negative Emotion (Distressed, Easily Upset)
.
Description: Degree to which people experience persistent negative emotions (anxiety, anger, or depression) and are easily upset. (This could be thought of as high threat sensitivity or low stress tolerance.)
Descriptors: Emotional instability, anxiety, irritability, depression, rumination-compulsiveness, self-consciousness, vulnerability
MRI Research*: Negative Emotion was associated with increased volume of brain regions associated with threat, punishment, and negative emotions.
.
* Emotional Instability:
"I get emotional easily, often for very little reason."
"I get emotional over every little thing."
"My emotions are unpredictable."
"I never know where my emotions will go from moment to moment."
"I am a highly emotional person."
"I have much stronger emotional reactions than almost everyone else."
"My emotions sometimes change for no good reason."
"I get angry easily."
"I get upset easily."
"I change my mood a lot."
"I am a person whose moods go up and down easily."
"I get easily agitated."
"I can be stirred up easily."
.
* Anxiousness:
"I worry about almost everything."
"I'm always fearful or on edge about bad things that might happen."
"I always expect the worst to happen."
"I am a very anxious person."
"I get very nervous when I think about the future."
"I often worry that something bad will happen due to mistakes I made in the past."
"I am filled with doubts about things."
"I feel threatened easily."
"I am afraid of many things."
.
* Separation Insecurity:
"I fear being alone in life more than anything else."
"I can't stand being left alone, even for a few hours."
"I’d rather be in a bad relationship than be alone."
"I'll do just about anything to keep someone from abandoning me."
"I dread being without someone to love me."
.
* Submissiveness:
"I usually do what others think I should do."
"I do what other people tell me to do."
"I change what I do depending on what others want."
.
* Perseveration:
"I get stuck on one way of doing things, even when it's clear it won't work."
"I get stuck on things a lot."
"It is hard for me to shift from one activity to another."
"I get fixated on certain things and can’t stop."
"I feel compelled to go on with things even when it makes little sense to do so."
"I keep approaching things the same way, even when it isn’t working."
.
* Depression:
"I have no worth as a person."
"Everything seems pointless to me."
"I often feel like a failure."
"The world would be better off if I were dead."
"The future looks really hopeless to me."
"I often feel just miserable."
"I'm very dissatisfied with myself."
"I often feel like nothing I do really matters."
"I know I'll commit suicide sooner or later."
"I talk about suicide a lot."
"I feel guilty much of the time."
"I'm so ashamed by how I've let people down in lots of little ways."
"I am easily discouraged."
"I become overwhelmed by events."
.
("Emotional Stability vs. Negative Emotion" modified from "PID-5" by Kreuger RF, Derringer J, Markon KE, Watson D, Skodol AE and Between facets and domains: 10 aspects of the Big Five)
*MRI Research: Testing predictions from personality neuroscience. Brain structure and the big five.


The "Big 5 Factors" of Personality as Shown In Dogs

The same "Big 5 Factors" of personality found in humans can be found in dogs. This makes sense because dogs, like humans, are a social species.



AGREEABLENESS VS. ANTAGONISM
.
Agreeableness ("Friend")
.
Dog is friendly towards unfamiliar people.
Dog is friendly towards other dogs.
When off leash, dog comes immediately when called.
Dog willingly shares toys with other dogs.
Dog leaves food or objects alone when told to do so.
.
Antagonism ("Foe")
.
Dog is dominant over other dogs.
Dog is assertive with other dogs (e.g., if in a home with other dogs, when greeting).
Dog behaves aggressively towards unfamiliar people.
Dog shows aggression when nervous or fearful.
Dog aggressively guards coveted items (e.g., stolen item, treats, food bowl).
Dog is quick to sneak out through open doors, gates.

CONSCIENTIOUSNESS VS. DISINHIBITION
.
Conscientiousness ("Self-Controlled")
.
Dog works at tasks (e.g., getting treats out of a dispenser, shredding toys) until entirely finished.
Dog works hard all day herding or pulling a sleigh (if a "working dog" on the farm or in the snow). *
Dog is curious.
.
Disinhibition ("Disinhibited")
.
Dog is boisterous.
Dog seeks constant activity.
Dog is very excitable around other dogs.

OPENNESS TO EXPERIENCE vs. IMPAIRED INTELLECT
.
Open To Experience ("Open-Minded")
.
Dog is able to focus on a task in a distracting situation (e.g., loud or busy places, around other dogs).
.
Closed To Experience ("Closed-Minded")
.
Dog is slow to respond to corrections.
Dog ignores commands.
Dog is slow to learn new tricks or tasks.

SOCIABILITY (EXTRAVERSION) vs. DETACHMENT
.
Sociability ("Approach")
.
Dog is attention seeking (e.g., nuzzling, pawing or jumping up on family members looking for attention and physical contact).*
Dog seeks companionship from people.
Dog is affectionate.
.
Detachment ("Avoidance")
.
Dog is aloof.
Dog gets bored in play quickly.
Dog is lethargic.

EMOTIONAL STABILITY VS. NEGATIVE EMOTION
.
Emotional Stability ("Safety")
.
Dog tends to be calm.
Dog is relaxed when greeting people.
Dog is confident.
Dog adapts easily to new situations and environments.
.
Negative Emotion ("Danger")
.
Dog is anxious.
Dog is shy.
Dog behaves fearfully towards unfamiliar people.
Dog exhibits fearful behaviors when restrained.
Dog avoids other dogs.
Dog behaves fearfully towards other dogs.
Dog behaves submissively (e.g., rolls over, avoids eye contact, licks lips) when greeting other dogs.
.
Modified from Jones, A. C. (2009). Development and validation of a dog personality questionnaire. Ph.D. Thesis. University of Texas, Austin.

* New items added by Phillip W. Long MD

Notice the Personality Differences Between Dogs and Humans

Dogs and humans are strikingly similar on 4 of the "Big 5 Factors" of personality. However, dogs and humans are quite different on the "Conscientiousness" factor - because the canine brain isn't designed to organize work projects. That's why dogs don't build dog houses.

Two of the "Big 5 Factors" of dog personality are clearly a function of dogs being a social species that forms social hierarchies: (1) the "Agreeableness" factor describes "friend vs. foe" behaviors, and (2) the "Sociability" factor describes "approach vs. avoidance" behaviors.

The "Openness to Experience" describes the ability to learn from experience. The "Emotional Stability" factor describes "safety vs. danger" behaviors.

The Brain and the "Big-5 Factors" of Human and Dog Personality

It could be that the "Big-5 Factors" of personality represent some extremely basic brain functions. For example, when a young man approaches a young woman, she must: (1) decide whether he is friend or foe ["Agreeableness"], (2) decide if this represents safety or danger ["Emotional Stability"], (3) decide whether to approach or avoid him ["Sociability"], (4) decide whether to be self-controlled or disinhibited ["Conscientiousness"], and (5) learn from this experience ["Openness to Experience"].


Back to top



World Health Organization Acute Stress Disorder Treatment Guidelines - 1


World Health Organization Posttraumatic Stress Disorder Treatment Guidelines


World Health Organization Grief Treatment Guidelines


World Health Organization Stress Symptoms


World Health Organization Acute Stress Interventions

Treatment Guidelines

Treatment


Treating Patients With Acute Stress Disorder and Posttraumatic Stress Disorder - Summarized From APA Guideline (2004)

Effective Psychological Treatment

All effective psychological treatments for Anxiety Disorders incorporate one or more of the following: (1) cognitive exposure (mentally facing the fear), (2) behavioral exposure (physically facing the fear), (3) correcting maladaptive coping (eliminating the negative thinking and superstitious behaviors associated with the fear), and (4) reducing stressors (reducing health/economic/occupational/social stressors using a problem-solving approach).

  • Cognitive prolonged exposure:
    This involves the emotional and detailed recounting of the traumatic memory in the temporal order in which the events unfolded, including one's thoughts and feelings, either in one's imagination while giving a running commentary on what one visualizes, or in writing. This is usually repeated until the recounting no longer evokes high levels of distress, and until the trauma memories are experienced as memories rather than something happening all over again.
    • Prolonged exposure has been shown to be more effective than other forms of cognitive behavioral therapy (CBT)

  • Behavioral exposure to avoided situations:
    This involves real-life confrontation with now safe situations that the person avoids because they are associated with the trauma and evoke strong emotions or physical reactions (e.g., driving a car again after being involved in an accident; using elevators again after being assaulted in an elevator). Repeated exposures help the person realise that the feared situation is no longer dangerous and that the anxiety about it does not persist for ever.

  • Eye movement desensitization and reprocessing (EMDR)
    This treatment uses recall and verbalization of traumatic memories of an event, as well as multiple brief, interrupted exposures to traumatic material. Research has shown that factors other than eye movements are responsible for EMDR's therapeutic effect.
    • EMDR has demonstrated efficacy similar to other forms of cognitive behavioral therapy (CBT)

  • Psychoeducation and support
    Both appear to be helpful as early interventions to reduce the psychological sequelae of exposure to mass violence or disaster.

Pharmacological Treatment

  • Antidepressant Medication:
    Selective serotonin reuptake inhibitor (SSRI), tricyclic, and monoamine oxidase inhibitor (MAOI) antidepressant medication are recommended as first-line medication treatment for Post-traumatic Stress Disorder.

  • Benzodiazepines:
    • May be useful in reducing anxiety and improving sleep.
    • Carry a high risk for dependence.
    • Benzodiazepine withdrawal may worsen symptoms.

Treatment - Summarized From U.S. Department of Defense, Veterans Affairs Guideline (2010)

Strength of Recommendations Rating System

A A strong recommendation that the clinicians provide the intervention to eligible patients.
Good evidence was found that the intervention improves important health outcomes and concludes that benefits substantially outweigh harm.
B A recommendation that clinicians provide (the service) to eligible patients.
At least fair evidence was found that the intervention improves health outcomes and concludes that benefits outweigh harm.
C No recommendation for or against the routine provision of the intervention is made.
At least fair evidence was found that the intervention can improve health outcomes, but concludes that the balance of benefits and harms is too close to justify a general recommendation.
D Recommendation is made against routinely providing the intervention to asymptomatic patients.
At least fair evidence was found that the intervention is ineffective or that harms outweigh benefits.
I The conclusion is that the evidence is insufficient to recommend for or against routinely providing the intervention.
Evidence that the intervention is effective is lacking, or poor quality, or conflicting, and the balance of benefits and harms cannot be determined.
.

Major Recommendations

Module A: Management of ASR and Prevention of PTSD

  1. Assessment and Triage
    1. Trauma Exposure (within the past 30 days)

      Acute Stress Reaction (ASR) is a transient condition that often develops in response to a traumatic event. Traumatic events are events that cause a person to fear that he/she may die or be seriously injured or harmed. These events also can be traumatic when the person witnesses them happening to others. Such events often create feelings of intense fear, helplessness, or horror for those who experience them. The traumatic events that can lead to an acute stress reaction are of similar severity to those involved in PTSD.

      Combat or Operational Stress Reaction (COSR) is an acute stress reaction of service members during Ongoing Military Operations. COSR specifically refers to a reaction to high-stress events and potentially traumatic event exposure. This reaction is not attributed to an identified medical/surgical condition that requires other urgent treatment (a service member can have COSR concurrent with minor wounds/illnesses).

    1. Assess Briefly Based on General Appearance and Behavior

      Objective

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

      Recommendations

      1. Identification of a patient with ASR symptoms is based on observation of behavior and function; there is insufficient evidence to recommend a specific screening tool.
      2. Individuals exhibiting the following responses to trauma should be screened for ASR:
        1. Physical: exhaustion, hyperarousal, somatic complaints (gastrointestinal [GI], genitourinary [GU], musculoskeletal [MS], cardiovascular [CV], respiratory, nervous system [NS]), or symptoms of conversion disorder
        2. Emotional: anxiety, depression, guilt/hopelessness
        3. Cognitive/mental: amnestic or dissociative symptoms, hypervigilance, paranoia, intrusive re-experiencing
        4. Behavioral: avoidance, problematic substance use.
      1. Individuals who experience ASR should receive a comprehensive assessment of their symptoms to include details about the time of onset, frequency, course, severity, level of distress, functional impairment, and other relevant information.
      2. Assess for capability to perform routine functions.

      Assessment Specific to COSR

      1. Assess service member's functional status, to include:
        1. Any changes in productivity
        2. Co-worker or supervisor reports of recent changes in appearance, quality of work, or relationships
        3. Any tardiness/unreliability, loss of motivation, or loss of interest
        4. Forgetful or easily distracted
        5. Screening for substance use
      1. Document symptoms of COSR and obtain collateral information from unit leaders, coworkers, or peers about stressors, function, medical history, and absence or impairment in operation or mission.
      2. Consider the service member's role and functional capabilities and the complexity and importance of his/her job.
    1. Unstable, Dangerous to Self or Others, or Need for Urgent Medical Attention

      Objective

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

      Recommendations

      1. Address acute medical/behavioral issues to preserve life and avoid further harm by:
        1. Providing appropriate medical/surgical care or referring to stabilize
        2. Evaluating the use of prescribed medications
        3. Preventing possible biological or chemical agent exposure
        4. Managing substance intoxication or withdrawal
        5. Stopping self-injury or mutilation
        6. Addressing inability to care for oneself.
      1. Arrange a safe, private, and comfortable environment for continuation of the evaluation:
        1. Assess danger to self or others (e.g., suicidal or homicidal behavior)
        2. Establish a working treatment alliance with the patient
        3. Maintain a supportive, non-blaming, non-judgmental stance throughout the evaluation
        4. Assist with the removal of any ongoing exposure to stimuli associated with the traumatic event
        5. Minimize further traumas that may arise from the initial traumatic event
        6. Assess and optimize social supports
        7. Secure any weapons and explosives
      1. Legal mandates should be followed:
        1. Reporting of violence, assault
        2. Confidentiality for the patient
        3. Mandatory testing
        4. Attending to chain of evidence in criminal cases (e.g., rape, evaluation)
        5. Involuntary commitment procedures if needed
      1. Carefully consider the following potential interventions to secure safety:
        1. Find safe accommodation and protect against further trauma
        2. Voluntary admission if suicidal
        3. Restraint/seclusion only if less restrictive measures are ineffective
        4. Provide medications managing specific symptoms as needed (e.g., sleep, pain)
      1. Educate and "normalize" observed psychological reactions to the chain of command.
      2. Evacuate to next level of care if unmanageable, if existing resources are unavailable, or if reaction is outside of the scope of expertise of the care provider.
    1. Ensure Basic Physical Needs Are Met

      Objective

      Ensure that trauma-exposed persons with acute stress symptoms have their basic needs met.

      Recommendations

      1. Acute intervention should ensure that the following needs are met:
        1. Safety/security/survival
        2. Food, hydration, clothing, hygiene, and shelter
        3. Sleep
        4. Medications (i.e., replace medications destroyed/lost)
        5. Education as to current status
        6. Communication with family, friends, and community
        7. Protection from ongoing threats/toxins/harm. If indicated, reduce use of alcohol, tobacco, caffeine, and illicit psychoactive substances.
      1. Provide Psychological First Aid to:
        1. Protect survivors from further harm
        2. Reduce physiological arousal
        3. Mobilize support for those who are most distressed
        4. Keep families together and facilitate reunion with loved ones
        5. Provide information and foster communication and education
        6. Use effective risk communication techniques

      Interventions Specific for Members of Pre-existing Group (e.g., COSR)

      1. Treat according to member's prior role and not as a "patient."
      2. Assure or provide the following, as needed:
        1. Reunion or ongoing contact with group/unit
        2. Promote continuity with established relationships (e.g., primary group)
        3. Respite from intense stress
        4. Comfortable environment (e.g., thermal comfort)
        5. Consider psychoeducation and discussion in a group format
        6. Assign job tasks and recreational activities that will restore focus and confidence and reinforce teamwork (limited duty).
    1. Person Has Trauma-Related Symptoms, Significant Impaired Function, or Diagnosis of ASD

      Objective

      Identify patients who have excessive post-traumatic stress symptoms or significant distress impaired function, or are diagnosed with ASD.

      Recommendations

      1. Acutely traumatized people, who meet the criteria for diagnosis of ASD, and those with significant levels of post-trauma symptoms after at least two weeks post-trauma, as well as those who are incapacitated by acute psychological or physical symptoms, should receive further assessment and early intervention to prevent PTSD.
      2. Trauma survivors, who present with symptoms that do not meet the diagnostic threshold for ASD, or those who have recovered from the trauma and currently show no symptoms, should be monitored and may benefit from follow-up and provision of ongoing counseling or symptomatic treatment.
      3. Service members with COSR who do not respond to initial supportive interventions may warrant referral or evacuation.
    1. Assess Medical and Functional Status

      Objectives

      Obtain complete history, physical examination, relevant laboratory tests, and assessment of functioning to determine course of treatment.

      Recommendations

      1. Medical status should be obtained for all persons presenting with symptoms to include:
        1. History, physical examination, and a neurological examination
        2. Use of prescribed medications, mood or mind-altering substances, and possible biological or chemical agent exposure
        3. A mini-mental status examination (MMSE) to assess cognitive function if indicated.
      1. The history and physical examination findings should lead the provider to other assessments as clinically indicated. Based on the clinical presentation, assessment may include:
        1. Screen for toxicology if the symptom presentation indicates
        2. Radiological assessment of patients with focal neurological findings or possible head injury
        3. Appropriate laboratory studies to rule out medical disorders that may cause symptoms of acute stress reactions (e.g., complete blood count [CBC], chemistry profile, thyroid studies, human chorionic gonadotropin [HCG], electrocardiogram [EKG], electroencephalogram [EEG])
      1. A focused psychosocial assessment should be performed to include assessment of active stressors, losses, current social supports, and basic needs (e.g., housing, food, and financial resources).
      2. A brief assessment of function should be completed to evaluate: 1) objectively impaired function based on general appearance and behavior; 2) subjectively impaired function; 3) baseline level of function (LOF) vs. current LOF; and 4) family and relationship functioning.
    1. Assess Pre-Existing Psychiatric and Medical Conditions

      Objective

      Identify patients at risk for complications.

      Recommendations

      1. Assess patients for pre-existing psychiatric conditions to identify high-risk individuals and groups.
      2. Assure access and adherence to medications that the patient is currently taking.
      3. Refer patients with pre-existing psychiatric conditions to mental health specialty when indicated or emergency hospitalization if needed.
    1. Assess Risk Factors for Developing ASD/PTSD

      Recommendations

      1. Trauma survivors who exhibit symptoms or functional impairment should be screened for the following risk factors for developing ASD/PTSD:

        Pre-traumatic Factors

        1. Ongoing life stress
        2. Lack of social support
        3. Young age at time of trauma
        4. Pre-existing psychiatric disorders, or substance misuse
        5. History of traumatic events (e.g., motor vehicle accident [MVA])
        6. History of PTSD
        7. Other pre-traumatic factors, including: female gender, low socioeconomic status, lower level of education, lower level of intelligence, race (Hispanic, African-American, American Indian, and Pacific Islander), reported abuse in childhood, report of other previous traumatization, report of other adverse childhood factors, family history of psychiatric disorders, and poor training or preparation for the traumatic event.

        Peri-traumatic or Trauma-related Factors

        1. Severe trauma
        2. Physical injury to self or others
        3. Type of trauma (combat, interpersonal traumas such as killing another person, torture, rape, or assault convey high risk of PTSD)
        4. High perceived threat to life of self or others
        5. Community (mass) trauma
        6. Other peri-traumatic factors, including: history of peri-traumatic dissociation.

        Post-traumatic Factors

        1. Ongoing life stress
        2. Lack of positive social support
        3. Bereavement or traumatic grief
        4. Major loss of resources
        5. Negative social support (shaming or blaming environment)
        6. Poor coping skills
        7. Other post-traumatic factors, including: children at home and a distressed spouse.
  1. Treatment
    1. Provide Education and Normalization/Expectancy of Recovery

      Objective

      Help trauma survivors cope with ASR/COSR by providing information that may help them manage their symptoms and benefit from treatment.

      Recommendations

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

      Objective

      To lessen the physical, psychological, and behavioral morbidity associated with acute stress reaction (ASR), hasten the return to full function (duty), and reduce the risk for development of ASD or PTSD following a traumatic event.

      Recommendations

      The following treatment recommendations should apply for all acutely traumatized people who meet the criteria for diagnosis of ASD, and for those with significant levels of acute stress symptoms that last for more than two weeks post-trauma, as well as those who are incapacitated by acute psychological or physical symptoms.

      1. Continue providing psychoeducation and normalization.
      2. Treatment should be initiated after education, normalization, and Psychological First Aid has been provided and after basic needs following the trauma have been made available.
      3. There is insufficient evidence to recommend for or against the use of Psychological First Aid to address symptoms beyond 4 days following trauma. [I]
      4. Survivors who present symptoms that do not meet the diagnostic threshold of ASD or PTSD should be monitored and may benefit from follow-up and provision of ongoing counseling or symptomatic treatment.
      5. Recommend monitoring for development of PTSD using validated symptom measures (e.g., PTSD Checklist, other screening tools for ASD/PTSD).
      6. Psychotherapy:
        1. Consider early brief intervention (4 to 5 sessions) of cognitive-based therapy (CBT) that includes exposure-based therapy, alone or combined with a component of cognitive re-structuring therapy for patients with significant early symptom levels, especially those meeting diagnostic criteria for ASD. [A]
        2. Routine formal psychotherapy intervention for asymptomatic individuals is not beneficial and may be harmful. [D]
        3. Strongly recommend against individual Psychological Debriefing as a viable means of reducing ASD or progression to PTSD. [D]
        4. The evidence does not support a single session group Psychological Debriefing as a viable means of reducing ASD or progression to PTSD, but there is no evidence of harm (Note: this is not a recommendation pertaining to Operational Debriefing). [D]
        5. Groups may be effective vehicles for providing trauma-related education, training in coping skills, and increasing social support, especially in the context of multiple group sessions. [I]
        6. Group participation should be voluntary.
      1. Pharmacotherapy:
        1. There is no evidence to support a recommendation for use of a pharmacological agent to prevent the development of ASD or PTSD. [I]
        2. Strongly recommend against the use of benzodiazepines to prevent the development of ASD or PTSD [D]
    1. Acute Symptom Management

      Recommendations

      1. Symptom-specific treatment should be provided after education, normalization, and basic needs are met.
      2. Consider a short course of medication (less than 6 days), targeted for specific symptoms in patients post-trauma
        1. Sleep disturbance/insomnia
        2. Management of pain
        3. Irritation/excessive arousal/anger
      1. Provide non-pharmacological intervention to address specific symptoms (e.g., relaxation, breathing techniques, avoiding caffeine) to address both general recovery and specific symptoms (sleep disturbance, pain, hyperarousal, or anger).

    L1. Facilitate Spiritual Support

    Recommendations

    1. Ensure patient access to spiritual care when sought.
    2. Assess for spiritual needs.
    3. Provide opportunities for grieving for losses (providing space and opportunities for prayers, mantras, rites, and rituals and end-of-life care, as determined important by the patient).

    L2. Facilitate Social Support

    1. Immediately after trauma exposure, preserve an interpersonal safety zone protecting basic personal space (e.g., privacy, quiet, personal effects).
    2. As part of Psychological First Aid, reconnect trauma survivors with previously supportive relationships (e.g., family, friends, unit members) and link with additional sources of interpersonal support.
    3. Assess for impact of PTSD on social functioning.
    4. Facilitate access to social support and provide assistance in improving social functioning, as indicated.
  1. Re-assessment
    1. Reassess Symptoms and Function

      Objective

      Identify patients with persistent traumatic stress symptoms, related dysfunction, or additional treatment needs.

      Recommendations

      1. Assessment of the response to the acute intervention should include an evaluation for the following risk factors:
        1. Persistent or worsening traumatic stress symptoms (e.g., dissociation, panic, autonomic arousal, cognitive impairment)
        2. Significant functional impairments (e.g., role/work, relationships)
        3. Dangerousness (suicidal or violent ideation, plan, and/or intent)
        4. Severe psychiatric co-morbidity (e.g., psychotic spectrum disorder, substance use disorder or abuse)
        5. Maladaptive coping strategies (e.g., pattern of impulsivity, social withdrawal, or other reactions under stress)
        6. New or evolving psychosocial stressors
        7. Poor social supports
      1. Follow-up after acute intervention to determine patient status should include the following:
        1. Patient does not improve or status worsens – continue management of PTSD (see Module B below) in consultation or referral to PTSD specialty care or mental health provider. Recommend involvement of the primary care provider in the treatment. Patients with multiple problems may benefit from a multi-disciplinary approach to include occupational therapy, spiritual counseling, recreation therapy, social work, psychology, and/or psychiatry.
        2. Patient demonstrates partial improvement (e.g., less arousal, but no improvement in sleep) – consider augmentation or adjustment of the acute intervention and follow up within 2 weeks.
        3. Patient recovers from acute symptoms – provide education about acute stress reaction and contact information with instructions for available follow-up if needed.
  1. Follow-up
    1. Persistent (>1 Month) or Worsening Symptoms, Significant Functional Impairment, or High Risk for Development of PTSD

      Objective

      Identify patients with PTSD or high risk for developing PTSD who may benefit from PTSD treatment.

      Recommendations

      1. Individuals who fail to respond to early interventions should be referred for PTSD treatment when they have:
        1. Worsening of stress-related symptoms
        2. High potential or new-onset potential for dangerousness
        3. Development of ASD/PTSD
        4. Maladaptive coping with stress (e.g., social withdrawal, alcohol use)
        5. Exacerbation of pre-existing psychiatric conditions
        6. Deterioration in function
        7. New onset stressors
        8. Poor social supports.
      1. Primary Care provider should consider initiating therapy pending referral or if the patient is reluctant or unable to obtain specialty services.
      2. Primary Care provider should continue evaluating and treating co-morbid physical illnesses and addressing any other health concerns, as well as educating and validating the patient regarding his/her illness.
    1. Monitor and Follow-Up

      Recommendations

      1. Follow-up should be offered to individuals who request it or to those at high risk of developing adjustment difficulties following exposure to major incidents and disasters, including individuals who:
        1. Have ASD or other clinically significant symptoms stemming from the trauma
        2. Are bereaved
        3. Have a pre-existing psychiatric disorder
        4. Require medical or surgical attention
        5. Were exposed to a major incident or disaster that was particularly intense and of long duration
      1. Primary Care providers should follow-up with patients about issues related to trauma in an ongoing way. Patients with initial sub-threshold presentation are at increased risk of developing PTSD and may need symptom-specific management.

Module B: Management of PTSD

  1. Assessment
    1. Assessment of Stress Related Symptoms

      Recommendations

      1. Patients who are presumed to have symptoms of PTSD or who are positive for PTSD on the initial screening should receive a thorough assessment of their symptoms that includes details such as time of onset, frequency, course, severity, level of distress, functional impairment, and other relevant information to guide accurate diagnosis and appropriate clinical decision-making.
      2. Consider use of a validated, self-administered checklist to ensure systematic, standardized, and efficient review of the patient's symptoms and history of trauma exposure. Routine ongoing use of these checklists may allow assessment of treatment response and patient progress (see Appendix C in the original guideline document).
      3. Diagnosis of PTSD should be obtained based on a comprehensive clinical interview that assesses all the symptoms that characterize PTSD. Structured diagnostic interviews, such as the Clinician-Administered PTSD scale (CAPS), may be considered.
    1. Assessment of Trauma Exposure
      1. Assessment of the trauma exposure experience should include:
        1. History of exposure to traumatic event(s)
        2. Nature of the trauma
        3. Severity of the trauma
        4. Duration and frequency of the trauma
        5. Age at time of trauma
        6. Patient's reactions during and immediately following trauma exposure (e.g., helplessness, horror, and fear)
        7. Existence of multiple traumas
      1. If trauma exposure is recent (<1 month), particular attention should be given to the following:
        1. Exposure to/environment of trauma
        2. Ongoing traumatic event exposure
        3. Exposure, perhaps ongoing, to environmental toxins
        4. Ongoing perceived threat
      1. When assessing trauma exposure, the clinician must consider the patient's ability to tolerate the recounting of traumatic material, since it may increase distress and/or exacerbate PTSD symptoms.
    1. Assessment of Dangerousness to Self or Others
      1. All patients with PTSD should be assessed for safety and dangerousness, including current risk to self or others, as well as historical patterns of risk:
        1. Suicidal or homicidal ideation, intent (plan), means (e.g., weapon, excess medications), history (e.g., violence or suicide attempts), behaviors (e.g., aggression, impulsivity), co-morbidities (substance abuse, medical conditions) [B]
        2. Family and social environment – including domestic or family violence, risks to the family [B]
        3. Ongoing health risks or risk-taking behavior [B]
        4. Medical/psychiatric co-morbidities or unstable medical conditions [B]
        5. Potential to jeopardize mission in an operational environment. [I]
    1. Obtain Medical History, Physical Examination, Laboratory Tests and Psychosocial Assessment

      Objective

      Obtain comprehensive patient data in order to reach a working diagnosis.

      Recommendations

      1. All patients should have a thorough assessment of medical and psychiatric history, with particular attention paid to the following:
        1. Baseline functional status
        2. Baseline mental status
        3. Medical history: to include any injury (e.g., mild traumatic brain injury [mTBI])
        4. Medications: to include medication allergies and sensitivities; prescription medications; herbal or nutritional supplements; and over-the?counter (OTC) medications (caffeine, energy drinks, or use of other substances)
        5. Past psychiatric history: to include prior treatment for mental health and substance use disorder, and past hospitalization for depression or suicidality
        6. Current life stressors
      1. All patients should have a thorough physical examination. On physical examination, particular attention should be paid to the neurological exam and stigmata of physical/sexual abuse, self-mutilation, or medical illness. Note distress caused by, or avoidance of, diagnostic tests/examination procedures.
      2. All patients, particularly the elderly, should have a Mental Status Examination (MSE) to include assessment of the following:
        1. Appearance and behavior
        2. Language/speech
        3. Thought process (loose associations, ruminations, obsessions) and content (delusions, illusions, and hallucinations)
        4. Mood (subjective)
        5. Affect (to include intensity, range, and appropriateness to situation and ideation)
        6. Level of consciousness (LOC)
        7. Cognitive function
        8. All patients should have routine laboratory tests as clinically indicated, such as thyroid stimulating hormone (TSH), complete metabolic panel, hepatitis, human immunodeficiency virus (HIV), and HCG (for females). Also consider CBC, urinalysis (UA), Tox (toxicology)/EtoH (ethanol) panel, and other tests
        9. Other assessments may be considered (radiology studies, ECG, and EEG), as clinically indicated
        10. All patients should have a narrative summary of psychosocial assessments to include work/school, family, relationships, housing, legal, financial, unit/community involvement, and recreation, as clinically appropriate.
    1. Assessment of Function, Duty/Work Responsibilities and Patient's Fitness (In Relation to Military Operations)

      Recommendations

      1. Assessment of function should be obtained through a comprehensive narrative assessment (see Table B-2 in the original guideline document), and the use of standardized, targeted, and validated instruments designed to assess family/relationship, work/school, and/or social functioning.
      2. The determination of when to return to work/duty should take into consideration the complexity and importance of the patient's job role and functional capabilities.
      3. The continuing presence of symptoms of PTSD should not be considered in itself as sufficient justification for preventing a return to work/duty.
    1. Assessment of Risk/Protective Factors

      Recommendations

      1. Patients should be assessed for risk factors for developing PTSD. Special attention should be given to post-traumatic factors (i.e., social support, ongoing stressors, and functional incapacity) that may be modified by intervention.
      2. When evaluating risk factors for PTSD, the clinician should keep in mind that PTSD is defined as occurring only after four weeks have elapsed following a traumatic event. PTSD symptoms, however, may not appear until a considerable time has passed—sometimes surfacing years later.

      See the original guideline document for a listing of risk factors.

  1. Triage
    1. Diagnosis of PTSD or Clinical Significant Symptoms Suggestive of PTSD?

      Recommendations

      1. A diagnosis of stress-related disorder consistent with the DSM IV criteria for PTSD should be formulated before initiating treatment.
      2. Diagnosis of PTSD should be obtained based on a comprehensive clinical interview that assesses all the symptoms that characterize PTSD. Structured diagnostic interviews, such as the Clinician-Administered PTSD scale (CAPS), may be considered.
      3. When a diagnostic work-up cannot be completed, primary care providers should consider initiating treatment or referral based on a working diagnosis of stress-related disorder.
      4. Patients with difficult or complicated presentation of the psychiatric component should be referred to PTSD specialty care for diagnosis and treatment.
      5. Patients with partial or sub-threshold PTSD should be carefully monitored for deterioration of symptoms.
    1. Assess for Co-Occurring Disorders

      Objective

      Improve management of PTSD symptoms when they are complicated by the presence of a medical or psychiatric co-morbidity.

      Recommendations

      1. Providers should recognize that medical disorders/symptoms, mental health disorders, and psychosocial problems commonly coexist with PTSD and should screen for them during the evaluation and treatment of PTSD.
      2. Because of the high prevalence of psychiatric co-morbidities in the PTSD population, screening for depression and other psychiatric disorders is warranted.
      3. Patterns of current and past use of substance by persons with trauma histories or PTSD should be routinely assessed to identify substance misuse or dependency (alcohol, nicotine, prescribed drugs, and illicit drugs).
      4. Pain (acute and chronic) and sleep disturbances should be assessed in all patients with PTSD.
      5. Generalized physical and cognitive health symptoms - also attributed to concussion/mTBI and many other causes – should be assessed and managed in patients with PTSD and co-occurring diagnosis of mTBI.
      6. Associated high-risk behaviors (e.g., smoking, alcohol/drug abuse, unsafe weapon storage, dangerous driving, and HIV and hepatitis risks) should be assessed in patients with PTSD.
      7. Providers should consider the existence of co-morbid conditions when deciding whether to treat patients in the primary care setting or refer them for specialty mental healthcare (See Annotation J).
      8. Patients with complicated co-morbidity may be referred to mental health or PTSD specialty care for evaluation and diagnosis (see Annotation J).
    1. Educate Patient and Family

      Objective

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

      Recommendations

      1. Trauma survivors and their families should be educated about PTSD symptoms, other potential consequences of exposure to traumatic stress, practical ways of coping with traumatic stress symptoms, co-morbidity with other medical health concerns, processes of recovery from PTSD, and the nature of treatments. [C]
      2. Providers should explain to all patients with PTSD the range of available and effective options for PTSD treatment.
      3. Patient preferences along with provider recommendations should drive the selection of treatment interventions in a shared and informed decision-making process.
    1. Determine Optimal Setting for Management of PTSD and Co-Occurring Disorders

      J1. Management of PTSD with Co-morbidity

      Recommendations

      Consultation/Referral

      1. PTSD and co-morbid mental health conditions should be treated concurrently for all conditions through an integrated treatment approach, which considers patient preferences, provider experience, severity of the conditions, and the availability of resources.
      2. Patients with PTSD and severe co-morbid mental health conditions should be treated either through referral or in consultation with a provider that is experienced in treating the co-morbid conditions.
      3. Because of the profound social impairment of PTSD (caused, for example, by the patient's anger and avoidance symptoms), close friends and family members in the patient's immediate daily environment (e.g., parents, spouse, or children) should be provided with education and advised to consider assistance from specialty care, both for individual treatment and couples/family treatment.
      4. Factors to consider when determining the optimal setting for treatment include:
        1. Severity of the PTSD or co-occurring disorders
        2. Local availability of service options (specialized PTSD programs, evidence-based treatments, behavioral health specialty care, primary care, integrated care for co-occurring disorders, Veterans Centers, other)
        3. Level of provider comfort and experience in treating psychiatric co-morbidities
        4. Patient preferences
        5. The need to maintain a coordinated continuum of care for chronic co-morbidities
        6. Availability of resources and time to offer treatment
      1. Considerations related to possible referral:

        Complicated severe PTSD: Some patients with PTSD have complicated, challenging presentations. These patients warrant referral to specialty PTSD care that includes access to cognitive-behavioral evidence-based treatments (see Module I-2: Treatment for PTSD).

        Co-occurring major depressive disorder (MDD) in the absence of significant suicidality, panic, or generalized anxiety often shows reduction in intensity when the PTSD is treated. Depression of mild severity may not require referral to specialty care or additional treatments outside those targeting PTSD. Patients should be carefully monitored for changes in symptoms. A reduction of PTSD symptoms that is not accompanied by reduction of symptoms in depression or anxiety would justify a more formally targeted treatment.

        Co-occurring mild to moderate disorders, such as substance use, pain disorders, and sleep problems, can frequently be effectively treated in the context of PTSD treatment and do not require a referral to specialty care. Consultation, to integrate adjunctive interventions, may be considered.

        Co-occurring severe psychiatric disorders, while not precluding concurrent PTSD treatment, typically justify referral to specialty care for evaluation and treatment. These disorders may include: severe major depression or major depression with suicidality, unstable bipolar disorder, severe personality disorders, psychotic disorders, significant TBI, and severe substance use disorder (SUD) or substance abuse of such intensity that PTSD treatment components are likely to be difficult to implement.

        Persistent post-concussion symptoms in patients who present with PTSD and a history of concussion/mTBI may be best managed within either primary care or polytrauma rehab settings that utilize a multidisciplinary team approach. Providers should recognize that mTBI/concussion is one of numerous possible etiologies of co-morbid post-deployment symptoms occurring in veterans and service members with PTSD, and it is often difficult to precisely attribute symptoms to concussive events that occurred months or years earlier. From a treatment standpoint, physical or cognitive symptoms, such as headaches or memory problems, or other persistent post-concussive symptoms should be treated symptomatically whether or not concussion/mTBI is thought to be one of the causal factors. Clinicians should not get caught up in debating causation but maintain focus on identifying and treating the symptoms that are contributing to the most impairment. There is no evidence to support withholding PTSD treatments while addressing post-concussive symptoms.

      J2. Management of Concurrent PTSD and SUD

      Objective

      Improve management of PTSD symptoms when they are complicated by a concurrent substance abuse problem.

      Recommendations

      1. All patients diagnosed with PTSD should receive comprehensive assessment for SUD, including nicotine dependence.
      2. Recommend and offer cessation treatment to patients with nicotine dependence. [A]
      3. Patients with SUD and PTSD should be educated about the relationships between PTSD and substance abuse. The patient's prior treatment experience and preference should be considered since no single intervention approach for the co-morbidity has yet emerged as the treatment of choice.
      4. Treat other concurrent substance use disorders including concurrent pharmacotherapy:
        1. Addiction-focused pharmacotherapy should be discussed, considered, available and offered, if indicated, for all patients with alcohol dependence and/or opioid dependence.
        2. Once initiated, addiction-focused pharmacotherapy should be monitored for adherence and treatment response.
      1. Provide multiple services in the most accessible setting to promote engagement and coordination of care for both conditions. [I]
      2. Reassess response to treatment for SUD periodically and systematically, using standardized and valid self-report instrument(s) and laboratory tests. Indicators of SUD treatment response include ongoing substance use, craving, side effects of medication, emerging symptoms, etc.
      3. There is insufficient evidence to recommend for or against any specific psychosocial approach to addressing PTSD that is co-morbid with SUD. [I]

      J3. The Role of the Primary Care Practitioner

      Recommendations

      1. Primary care providers should routinely provide the following services for all patients with trauma-related disorders, especially those who are reluctant to seek specialty mental healthcare:
        • Education about the disorder and importance of not letting stigma and barriers to care interfere with specialty treatment if needed
        • Provision of evidence-based treatment within the primary care or through referral
        • Regular follow-up and monitoring of symptoms
        • Regular follow-up and monitoring of co-morbid health concerns.
      1. Primary care providers should consider consultation with mental health providers for patients with PTSD who warrant a mental health referral but refuse it or seem reluctant to talk to a mental health provider.
      2. Primary care providers should take leadership in providing a collaborative multi-disciplinary treatment approach. Team members may include the primary care providers, mental health specialists, other medical specialists (e.g., neurology, pain management), chaplains, pastors, social workers, occupational or recreational therapists, Veterans Center staff members, staff of family support centers, exceptional family member programs, VA benefits counselors, vocational rehabilitation specialists, peer counselors, and others.
      3. When an integrated behavioral health clinician is available (e.g., collaborative care model, or Post-Deployment Care clinics) evidence-based treatment should be provided.
      4. Primary care providers should continue to be involved in the treatment of patients with acute or chronic stress disorders. All patients with PTSD should have a specific primary care provider assigned to coordinate their overall healthcare.
  1. Treatment
    1. Initiate Treatment Using Effective Interventions for PTSD

      For Specific Treatment Modalities: See Module I-2 Treatment Interventions for PTSD below:

      • Psychotherapy
      • Pharmacotherapy
      • Adjunctive treatments
      • Somatic therapy
      • Complementary alternative therapy (CAM)

      Recommendations

      1. A supportive and collaborative treatment relationship or therapeutic alliance should be developed and maintained with patients with PTSD.
      2. Evidence-based psychotherapy and/or evidence-based pharmacotherapy are recommended as first-line treatment options.
      3. Specialized PTSD psychotherapies may be augmented by additional problem-specific methods/services and pharmacotherapy.
      4. Consider referral for alternative care modalities (complementary alternative medicine) for patient symptoms, consistent with available resources and resonant with patient belief systems (see Module I-2 below).
      5. Patients with PTSD who are experiencing clinically significant symptoms, including chronic pain, insomnia, anxiety, should receive symptom-specific management interventions (see Module I-3 below).
      6. Management of PTSD or related symptoms may be initiated based on a presumptive diagnosis of PTSD. Long-term pharmacotherapy will be coordinated with other intervention.
    1. Facilitate Spiritual Support (see Module I-2: D2 - Spiritual Support below)
    2. Facilitate Social Support (see Module A: L2 - Facilitate Social Support above)
  1. Re-assessment and Follow-up
    1. Assess Response to Treatment

      Objective

      Re-assess patient status following therapeutic intervention to determine response to treatment, inform treatment decisions, and identify need for additional services. Re-assessment should address PTSD symptoms, diagnostic status, functional status, quality of life, additional treatment needs, and patient preferences.

      Recommendations

      1. At a minimum, providers should perform a brief PTSD symptom assessment at each treatment visit. The use of a validated PTSD symptom measure, such as the PTSD Checklist, should be considered (see Appendix C in the original guideline document).
      2. Comprehensive re-assessment and evaluation of treatment progress should be conducted at least every 90 days, perhaps with greater frequency for those in active treatment, and should include a measure of PTSD symptomatology (e.g., PTSD checklist) and strongly consider a measure of depression symptomatology (e.g., Patient Health Questionnaire [PHQ]9).
      3. Other specific areas of treatment focus (e.g., substance abuse) should also be reevaluated and measured by standardized measures of outcome.
      4. Assessment of functional impairment should also be made, at a minimum, by asking patients to rate to what extent their symptoms make it difficult to engage in vocational, parental, spousal, familial, or other roles.
      5. Consider continued assessment of:
        • Patient preferences
        • Treatment adherence
        • Adverse treatment effects.
    1. Follow-up

      Recommendations

      1. If patient does not improve or status worsens, consider one of the following treatment modification options:
        1. Continue application of the same modality at intensified dose and/or frequency
        2. Change to a different treatment modality
        3. Apply adjunctive therapies
        4. Consider a referral to adjunctive services for treatment of co-morbid disorders or behavioral abnormalities (e.g., homelessness, domestic violence, or aggressive behavior)
        5. For patient with severe symptoms or coexisting psychiatric problems consider referrals to:
          • Specialized PTSD programs
          • Specialized programs for coexisting problems and conditions
          • Partial psychiatric hospitalization or "day treatment" programs
          • Inpatient psychiatric hospitalization
      1. If patient demonstrates partial (insufficient) remission, consider one of the following treatment modification options:
        1. Before making any therapeutic change, ensure that "treatment non?response" is not due to one or more of the following: not keeping psychotherapy appointments, not doing prescribed homework, not taking prescribed medications, still using alcohol or illicit substances, still suffering from ongoing insomnia or chronic pain, not experiencing any new psychosocial stressors, the original assessment did not overlook a co-morbid medical or psychiatric condition
        2. Continue the present treatment modality to allow sufficient time for full response
        3. Continue application of the same modality at intensified dose and/or frequency
        4. Change to a different treatment modality
        5. Apply adjunctive therapies
        6. Increase level of care (e.g., referral facility, partial hospitalization, inpatient hospitalization, residential care)
        7. Consider a referral to adjunctive services for treatment of co-morbid disorders or behavioral abnormalities (e.g., homelessness or domestic violence).
      1. If patient demonstrates improved symptoms and functioning but requires maintenance treatment:
        1. Continue current course of treatment
        2. Consider stepping down the type, frequency, or dose of therapy
        3. Consider:
          • Transition from intensive psychotherapy to case management contacts
          • Transition from individual to group treatment modalities
          • Transition to as-needed treatment
        1. Discuss patient status and need for monitoring with the primary care provider
        2. Consider a referral to adjunctive services for treatment of co-morbid disorders or behavioral abnormalities (e.g., homelessness or domestic violence).
      1. If patient demonstrates remission from symptoms and there are no indications for further therapy:
        1. Discontinue treatment
        2. Educate the patient about indications for and route of future care access
        3. Monitor by primary care for relapse/exacerbation.
      1. Evaluate psychosocial function and refer for psychosocial rehabilitation, as indicated. Available resources include, but are not limited to: chaplains, pastors, Family Support Centers, Exceptional Family Member Programs, VA benefits counselors, occupational or recreational therapists, Veterans Centers, and peer-support groups (see Module I-2: D - Psychosocial Rehabilitation below).
      2. Provide case management, as indicated, to address high utilization of medical resources.

Module I: Treatment Interventions for Post-traumatic Stress

Module I-1. Early Interventions to Prevent PTSD

Recommendations

The following treatment recommendations should apply for all acutely traumatized people who meet the criteria for diagnosis of ASD, and for those with significant levels of acute stress symptoms that last for more than two weeks post-trauma, as well as those who are incapacitated by acute psychological or physical symptoms.

  1. Continue providing psychoeducation and normalization
  2. Treatment should be initiated after education, normalization, and Psychological First Aid has been provided and after basic needs following the trauma have been made available.
  3. There is insufficient evidence to recommend for or against the use of Psychological First Aid to address symptoms beyond 4 days following trauma. [I]
  4. Survivors who present with symptoms that do not meet the diagnostic threshold of ASD or PTSD should be monitored and may benefit from follow-up and provision of ongoing counseling or symptomatic treatment.
  5. Recommend monitoring for development of PTSD using validated symptom measures (e.g., PTSD Checklist, other screening tools for ASD/PTSD).
  6. Psychotherapy:
    1. Consider early brief intervention (4 to 5 sessions) of CBT that includes exposure-based therapy, alone or combined with a component of cognitive re-structuring therapy for patients with significant early symptom levels, especially those meeting diagnostic criteria for ASD. [A]
    2. Routine formal psychotherapy intervention for asymptomatic individuals is not beneficial and may be harmful. [D]
    3. Strongly recommend against individual Psychological Debriefing as a viable means of reducing ASD or progression to PTSD. [D]
    4. The evidence does not support a single session group Psychological Debriefing as a viable means of reducing ASD or progression to PTSD, but there is no evidence of harm (Note: this is not a recommendation pertaining to Operational Debriefing). [D]
    5. Groups may be effective vehicles for providing trauma-related education, training in coping skills, and increasing social support, especially in the context of multiple group sessions. [I]
    6. Group participation should be voluntary.
  1. Pharmacotherapy:
    1. There is no evidence to support a recommendation for use of a pharmacological agent to prevent the development of ASD or PTSD. [I]
    2. Strongly recommend against the use of benzodiazepines to prevent the development of ASD or PTSD. [D]
  1. Psychotherapy

    See the original guideline document for information on specific types of psychotherapy including:

    • Psychological debriefing
    • Brief early cognitive-behavioral intervention
    • Other early interventions
  1. Early Pharmacotherapy Interventions to Prevent PTSD

    See the original guideline document for an explanation of early pharmacotherapy interventions.

Module I-2. Treatment for PTSD

  1. Selection of Therapy for PTSD

    Recommendations

    1. Providers should explain to all patients with PTSD the range of available and effective therapeutic options for PTSD.
    2. Patient education is recommended as an element of treatment of PTSD for all patients and the family members. [C]
    3. Patient and provider preferences should drive the selection of evidence-based psychotherapy and/or evidence-based pharmacotherapy as the first line treatment.
    4. Psychotherapies should be provided by practitioners who have been trained in the particular method of treatment.
    5. A collaborative care approach to therapy administration, with care management, may be considered, although supportive evidence is lacking specifically for PTSD.
  1. Psychotherapy Interventions for PTSD

    Recommendations

    Treatment Options

    1. Strongly recommend that patients who are diagnosed with PTSD should be offered one of the evidence-based trauma-focused psychotherapeutic interventions that include components of exposure and/or cognitive restructuring; or stress inoculation training. [A]

      The choice of a specific approach should be based on the severity of the symptoms, clinician expertise in one or more of these treatment methods, and patient preference, and may include an exposure-based therapy (ET) (e.g., prolonged exposure), a CBT (e.g., Cognitive Processing Therapy), stress management therapy (e.g., Stress Inoculation Therapy [SIT]) or Eye Movement Desensitization and Reprocessing (EMDR).

    1. Relaxation techniques should be considered as a component of treatment approaches for ASD or PTSD in alleviating symptoms associated with physiological hyper-reactivity. [C]
    2. Imagery Rehearsal Therapy (IRT) can be considered for treatment of nightmares and sleep disruption. [C]
    3. Brief psychodynamic therapy can be considered for patients with PTSD. [C]
    4. Hypnotic techniques can be considered, especially for symptoms associated with PTSD, such as pain, anxiety, dissociation, and nightmares, for which hypnosis has been successfully used. [C]
    5. There is insufficient evidence to recommend for or against Dialectical Behavioral Therapy (DBT) as first-line treatment for PTSD [I]
      • DBT can be considered for patients with a borderline personality disorder typified by parasuicidal behaviors. [B]
    1. There is insufficient evidence to recommend for or against family or couples therapy as first-line treatment for PTSD; family or couples therapy may be considered in managing PTSD-related family disruption or conflict, increasing support, or improving communication. [I]
    2. Group therapy may be considered for treatment of PTSD [C]
      • There is insufficient evidence to favor any particular type of group therapy over other types.
      • Patients being considered for group therapy should exhibit acceptance for the rationale for trauma work, and willingness to self-disclose in a group.
    1. Consider augmenting with other effective evidence-based interventions for patients who do not respond to a single approach.
    2. Supportive psychotherapy is not considered to be effective for the treatment of PTSD. However, multiple studies have shown that supportive interventions are significantly more helpful than no treatment, and they may be helpful in preventing relapse in patients who have reasonable control over their symptoms and are not in severe and acute distress.

    Note: Approaches may also be beneficial as parts of an effectively integrated approach. Most experienced therapists integrate diverse therapies, which are not mutually exclusive, in a fashion that is designed to be especially beneficial to a given patient.

    Delivery of Care

    1. Telemedicine interventions that involve person-to-person individual treatment sessions appear to have similar efficacy and satisfaction clinically as a direct face-to-face interaction, though data are much more limited than for face-to-face encounters. [C]
      1. Telemedicine interventions are recommended when face-to-face interventions are not feasible due to geographic distance between patient and provider or other barriers to patient access (e.g., agoraphobia, physical disability); when the patient would benefit from more frequent contact than is feasible with face-to-face sessions; or when the patient declines more traditional mental health interventions.
      2. Providers using telemedicine interventions should endeavor to maintain and strengthen the therapeutic relationship, build patient rapport, stress practice and assignment completion, and ensure adequacy of safety protocols using similar techniques as they do in a face-to-face session.
      3. Providers using technology-assisted interventions should take steps to ensure that their work complies with the regulations and procedures of the organization in which they are employed, legal standards, and the ethical standards of their professions. Patient confidentiality and safety should be monitored closely.
    1. There is insufficient evidence to recommend for or against Web-based interventions as a stand-alone intervention or as an alternative to standard mental health treatment for PTSD. [I]

      If used:

      1. Clinicians should carefully review the content of any web-based materials to ensure their accuracy and ethical application before recommending use to patients.
      2. Web-based approach may be used where face-to-face interventions are not feasible (e.g., geography limits access to other forms of treatment) or when patients decline more traditional mental health interventions. It has also been suggested that web-based interventions may provide more confidentiality than more traditional approaches.
      3. Providers should regularly encourage patients to complete the intervention and endeavor to maintain and strengthen the therapeutic relationship, build patient rapport, stress practice and assignment completion, and ensure adequacy of safety protocols. Availability of telephone contact for initial assessment or other reasons (e.g., emergencies, suicidality/homicidality, or follow-up of specific problems) should be considered.
      4. Providers using technology-assisted interventions should take steps to ensure that their work complies with the regulations and procedures of the organization in which they are employed, legal standards, and the ethical standards of their professions. Patient confidentiality and safety should be monitored closely.

    See the original guideline document for a discussion on the following types of psychotherapy interventions:

    • Therapies that More Strongly Emphasize Cognitive Techniques (CT)
    • ET
    • SIT
    • EMDR
    • IRT
    • Psychodynamic Therapy
    • Patient Education
    • Group Therapy
    • DBT
    • Hypnosis
    • Behavioral Couples Therapy
    • Telemedicine and Web-based Interventions
  1. Pharmacotherapy for PTSD

    Recommendations

    General Recommendations

    1. Risks and benefits of long-term pharmacotherapy should be discussed prior to starting medication and should be a continued discussion item during treatment.
    2. Monotherapy therapeutic trial should be optimized before proceeding to subsequent strategies by monitoring outcomes, maximizing dosage (medication or psychotherapy), and allowing sufficient response time (for at least 8 weeks). [C]
    3. If there is some response and patient is tolerating the drug, continue for at least another 4 weeks.
    4. If the drug is not tolerated, discontinue the current agent and switch to another effective medication.
    5. If no improvement is observed at 8 weeks consider:
      1. Increasing the dose of the initial drug to maximum tolerated
      2. Discontinuing the current agent and switching to another effective medication
      3. Augmenting with additional agents
    1. Recommend assessment of adherence to medication at each visit.
    2. Recommend assessment of side effects and management to minimize or alleviate adverse effects.
    3. Assess for treatment burden (e.g., medication adverse effects, attending appointments) after initiating or changing treatment, when the patient is non-adherent to treatment or when the patient is not responding to treatment.
    4. Since PTSD is a chronic disorder, responders to pharmacotherapy may need to continue medication indefinitely; however, it is recommended that maintenance treatment should be periodically reassessed.
    5. Providers should give simple educational messages regarding antidepressant use (e.g., take daily, understand gradual nature of benefits, continue even when feeling better, medication may cause some transient side effects, along with specific instructions on how to address issues or concerns, and when to contact the provider) in order to increase adherence to treatment in the acute phase. [B]

    Monotherapy

    1. Strongly recommend that patients diagnosed with PTSD should be offered selective serotonin reuptake inhibitors (SSRIs), for which fluoxetine, paroxetine, or sertraline have the strongest support, or serotonin norepinephrine reuptake inhibitors (SNRIs), for which venlafaxine has the strongest support, for the treatment of PTSD. [A]
    2. Recommend mirtazapine, nefazodone, tricyclic antidepressants (TCAs) (amitriptyline and imipramine), or monoamine oxidase inhibitors (phenelzine) for the treatments for PTSD. [B]
    3. Recommend against the use of guanfacine, anticonvulsants (tiagabine, topiramate, or valproate) as monotherapy in the management of PTSD. [D]
    4. The existing evidence does not support the use of bupropion, buspirone, trazodone, anticonvulsants (lamotrigine or gabapentin), or atypical antipsychotics as monotherapy in the management of PTSD. [I]
    5. There is evidence against the use of benzodiazepines in the management of PTSD. [D]
    6. There is insufficient evidence to support the use of prazosin as monotherapy in the management of PTSD. [I]

    Augmented Therapy for PTSD

    1. Recommend atypical antipsychotics as adjunctive therapy: risperidone or olanzapine [B] or, quetiapine [C].
    2. Recommend adjunctive treatment with prazosin for sleep/nightmares. [B]
    3. There is insufficient evidence to recommend a sympatholytic or an anticonvulsant as an adjunctive therapy for the treatment of PTSD. [I]

    See the original guideline document for a detailed discussion of pharmacotherapy treatment for PTSD.

  1. Adjunctive Services

    D1. Psychosocial Rehabilitation

    Recommendations

    1. Consider psychosocial rehabilitation techniques once the client and clinician identify the following kinds of problems associated with the diagnosis of PTSD: persistent high-risk behaviors, lack of self-care/independent living skills, homelessness, interactions with a family that does not understand PTSD, socially inactive, unemployed, and encounters with barriers to various forms of treatment/rehabilitation services.
    2. Patient and clinician should determine whether such problems are associated with core symptoms of PTSD and, if so, ensure that rehabilitation techniques are used as a contextual vehicle for alleviating PTSD symptoms.
    3. Psychosocial rehabilitation should occur concurrently or shortly after a course of treatment for PTSD, since psychosocial rehabilitation is not trauma-focused.

    D2. Spiritual Support

    Recommendation

    1. Assess for spiritual needs and facilitate access to spiritual/religious care when sought. [I]
  1. Somatic Treatment

    E1. Biomedical Somatic Therapies

    Objective

    Evaluate the evidence for efficacy of biomedical somatic therapies, including electroconvulsive therapy (ECT), cranial electrotherapy stimulation (CES), vagal nerve stimulation (VNS), repetitive transcranial magnetic stimulation (rTMS), and deep brain stimulation (DBS), in the treatment of PTSD.

    Recommendations

    1. There is insufficient evidence to recommend the use of any of the biomedical somatic therapies for first-line treatment of PTSD. [D]
    2. ECT and rTMS may be considered as an alternative in chronic, severe, medication- and psychotherapy-resistant PTSD. [B]

    E2. Acupuncture

    Objective

    Improve management of PTSD symptoms, particularly when accompanied by associated symptoms of chronic pain, depression, insomnia, anxiety, or substance abuse.

    Recommendation

    1. Acupuncture may be considered as treatment for patients with PTSD. [B]
  1. Complementary and Alternative Medicine (CAM)

    Objective

    Identify interventions derived from traditional and nontraditional complementary approaches that may provide effective first-line or adjunctive treatment for PTSD.

    Recommendations

    1. There is insufficient evidence to recommend CAM approaches as first line treatments for PTSD. [I]
    2. CAM approaches that facilitate a relaxation response (e.g., mindfulness, yoga, acupuncture, massage, and others) may be considered for adjunctive treatment of hyperarousal symptoms, although there is no evidence that these are more effective than standard stress inoculation techniques. [I]
    3. CAM approaches may be considered as adjunctive approaches to address some co-morbid conditions (e.g., acupuncture for pain). [C]
    4. CAM may facilitate engagement in medical care and may be considered in some patients who refuse evidence-based treatments. However, providers should discuss the evidence for effectiveness and risk-benefits of different options, and ensure that the patient is appropriately informed.

    See the original guideline document for a full list of complementary and alternative medicine modalities.

Module I-3. Management of Specific Symptoms

  1. Sleep Disturbances

    Recommendations (Based on Consensus of the Working Group Clinical Experts)

    Sleep Disturbance

    1. Encourage patients to practice good sleep hygiene, including:
      • Restricting the night-time sleep period to about eight hours
      • Waking at a regular time
      • Arising from bed at a regular time
      • Avoiding going to bed too early
      • Avoiding alcohol
      • Avoiding stimulants, caffeinated beverages, power/energy drinks, nicotine, and OTC medications
      • Avoiding stimulating activities, light, noise, and temperature extremes before bedtime (e.g., exercise, video games, TV) or in the sleeping area
      • Reducing (to less than 30 minutes), or abolishing, daytime naps
      • Practicing relaxation techniques
      • Engaging in moderate exercise, but not immediately before bedtime
    1. Offer CBT for insomnia, which may include:
      • Educating about proper sleep habits and sleep needs
      • Correcting false and unrealistic beliefs/concerns about sleep
      • Identifying and addressing anxious, automatic thoughts which disrupt sleep
    1. Consider adjunctive therapy for nightmares using prazosin. [B]
    2. Any significant change in sleep patterns should trigger clinical reassessment in order to rule out worsening or new onset of co-morbid conditions.

    Insomnia

    1. Monitor symptoms to assess improvement or deterioration and reassess accordingly.
    2. Explore cause(s) for insomnia, including co-morbid conditions.
    3. Begin treatment for insomnia with non-pharmacological treatments, including sleep hygiene and cognitive behavioral treatment (see recommendation for sleep disturbances above).
    4. The selection of sleep agents for the treatment of insomnia in PTSD patients may be impacted by other treatment decisions (e.g., medications already prescribed for the treatment of PTSD, depression, TBI, pain, or concurrent substance abuse/withdrawal) and social/environmental/logistical concerns associated with deployment.
      1. Trazodone may be helpful in management of insomnia and may also supplement the action of other antidepressants.
      2. Hypnotics are a second-line approach to the management of insomnia and should only be used for short periods of time. Should hypnotic therapy be indicated, the newer generation of non-benzodiazepines (e.g., zolpidem, eszopiclone, ramelteon) may have a safety advantage by virtue of their shorter half-life and lower risk of dependency. Patients should be warned of and monitored for the possibility of acute confusional states/bizarre sleep behaviors associated with hypnotic use. Benzodiazepines can be effective in chronic insomnia but may have significant adverse effects (confusion, sedation, intoxication) and significant risk of dependency.
      3. Atypical antipsychotics should be avoided due to potential adverse effects but may be of value when agitation or other symptoms are severe.
      4. If nightmares remain severe, consider adjunctive treatment with prazosin. [B]
      5. If symptoms persist or worsen, refer for evaluation and treatment of insomnia.
  1. Pain

    Recommendations (Based on Consensus of the Working Group Clinical Experts)

    1. Recommend pain assessment using a '0 to 10' scale.
    2. Obtain a thorough biopsychosocial history and assess for other medical and psychiatric problems, including risk assessment for suicidal and homicidal ideation and misuse of substances, such as drugs or alcohol and OTC and prescription drugs or narcotics.
    3. Assessment should include questions about the nature of the pain and likely etiology (i.e., musculoskeletal and neuropathic), locations, quality, quantity, triggers, intensity, and duration of the pain, as well as aggravating and relieving factors.
    4. Assessment should include evaluation of the impact of pain on function and activities, pain-related disability, or interference with daily activities.
    5. Assessment should include the identification of avoidance behaviors that contribute to emotional distress and/or impaired functioning.
    6. Management of pain should be multidisciplinary, addressing the physical, social, psychological, and spiritual components of pain in an individualized treatment plan that is tailored to the type of pain. [C]
    7. Selection of treatment options should balance the benefits of pain control with possible adverse effects (especially sedating medications) on the individual's ability to participate in, and benefit from, PTSD treatment. [I]
    8. Musculoskeletal pain syndromes can respond to correcting the underlying condition and treatment with non-steroidal anti-inflammatory drugs (NSAIDs).
    9. When appropriate, recommend use of non-pharmacological modalities for pain control, such as biofeedback, massage, imaging therapy, physical therapy, and complementary alternative modalities (yoga, meditation, acupuncture). [C]
    10. Centrally acting medications should be used in caution in patients with PTSD, as they may cause confusion and deterioration of cognitive performance and interfere with the recovery process.
      1. If required, lower doses of opioid therapy or other centrally acting analgesics should be used for short duration with transition to the use of NSAIDs. [C]
    1. Consider offering CBT, which may include:
      1. Encouraging increasing activity by setting goals
      2. Correcting false and unrealistic beliefs/concerns about pain
      3. Teaching cognitive and behavioral coping skills (e.g., activity pacing)
      4. Practicing and consolidation of coping skills and reinforcement of use
  1. Irritability, Severe Agitation, or Anger

    Recommendations (Based on Consensus of the Working Group Clinical Experts)

    1. Assess the nature of symptoms, severity, and dangerousness. Consider using standardized Anger Scales, such as Spielberger's State-Trait Anger Expression Inventory, to quantify.
    2. Explore for cause of symptoms and follow-up to monitor change.
    3. Consider referral to specialty care for counseling or for marital or family counseling as indicated. Offer referral for:
      1. Anger management therapy
      2. Training in exercise and relaxation techniques.
    1. Promote participation in enjoyable activities - especially with family/loved ones.
    2. Promote sleep and relaxation.
    3. Avoid stimulants and other substances (caffeine, alcohol).
    4. Address pain (see pain management above).
    5. Avoid benzodiazepines.
    6. Consider SSRIs/SNRIs
      1. If not responding to SSRIs/SNRIs and other non-pharmacological interventions, consider low-dose anti-adrenergics or low-dose atypical antipsychotics (risperidone, quetiapine).
      2. If not responding or worsening, refer to specialty care.


Back to top



Self-Help Resources For Posttraumatic Stress Disorder


Improving Positive Behavior

Philosophers for the past 2,500 years have taught that it is very beneficial to start the day with goal-setting, and end the day with a brief review.

This habit of planning the day in the morning, then assessing these plans in the evening has been shown to increase health and happiness. There is an additional benefit from doing a weekly review of your life satisfaction.

Note: When each of the following videos finishes; you must exit YouTube (by manually closing the window) in order to return to this webpage.



International Space Station (For Meditation)



Planning My Day (5-Minute Meditation Video)

Planning My Day (Picture)



Reviewing My Day Or Week (5-Minute Meditation Video)



Life Satisfaction Scale (Video)



Healthy Social Behaviors Scale (Video)



Mental Health Scale (Video)

Why We All Need to Practice Emotional First Aid



The Philosophy Of Stoicism (5 minute video)

Stoicism 101 (52 minute video)



The Roman emperor and Stoic philosopher Marcus Aurelius ruled from 161 to 180 A.D.

An Example Of Mindfulness Meditation (10 minute video)

In the 5th century BCE, Buddha spent 6 years of his life mastering mindfulness meditation. He then decided to look beyond meditation. Buddha concluded that simply emptying the mind of thought is calming, but otherwise it accomplishes little - since "You return to the same world". Instead, Buddha taught that we should change our world by seeking enlightenment through practicing compassion, and living a calm, peaceful, happy life.



7-Minute Workout Is All You Need To Get Back Into Physical Shape

Click Here For More Self-Help



Back to top




  • The best summary on bad research is given by Laura Arnold in this Tedx lecture. If you read nothing else about research, you owe it to yourself to watch this short video - it is excellent!

  • Criteria For High Quality Research Studies

  • It is imperative that medical researchers conduct high quality research studies, otherwise the US Food and Drug Administration (FDA) refuses to licence their new drug or therapy. In 2009, the cost of successfully licensing one new drug or therapy under the FDA scheme was estimated to be US$1,000 million. Thus psychiatric research which leads to FDA approval of a new drug or therapy has to be of the highest quality; however the majority of psychological research studies on new therapies fail to reach these high standards for research. This could explain why two-thirds of psychological research studies can't be replicated. High quality research must meet the following criteria:

    • Randomized Controlled Trial:
      Ask: Was the trial randomized? Was the randomization procedure described and was it appropriate? The best research design is to have research subjects randomly assigned to an experimental or control group. It is essential that confounding factors be controlled for by having a control group or comparator condition (no intervention, placebo, care as usual etc.).

    • Representative Sample:
      Ask: Do the research subjects represent a normal cross-section of the population being studied? Many psychological research studies using university students are flawed because their subjects are not representative of the normal population since they are all W.E.I.R.D. (White, Educated, Intelligent, Rich, and living in a Democracy).

    • Single Blind Trial:
      Ask: Was the treatment allocation concealed? It is essential that the research subjects are kept "blind" as to whether they are in the experimental or control group (in order to control for any placebo effects).

    • Double Blind Trial (Better Than Single Blind Trial):
      Ask: Were blind outcome assessments conducted? In a double blind study, neither the research subjects nor the outcome assessors know if the research subject is in the experimental or control group. This controls for both the placebo effect and assessor bias.

    • Baseline Comparability:
      Ask: Were groups similar at baseline on prognostic indicators? The experimental and control groups must be shown to be comparable at the beginning of the study.

    • Confounding Factors:
      Ask: Were there factors, that weren't controlled for, that could have seriously distorted the study's results? For example, research studies on the effectiveness of mindfulness cognitive therapy in preventing depressive relapse forgot to control for whether the research subjects were also simultaneously receiving antidepressant medication or other psychological treatments for depression.

    • Intervention Integrity:
      Ask: Was the research study protocal strictly followed? The research subjects must be shown to be compliant (e.g., taking their pills, attending therapy) and the therapists must be shown to be reliably delivering the intervention (e.g., staying on the research protocol).

    • Statistical analysis:
      Ask: Was a statistical power calculation described? The study should discuss its statistical power analysis; that is whether the study size is large enough to statistically detect a difference between the experimental and control group (should it occur) and usually this requires at least 50 research subjects in the study.

      Ask: Are the results both statistically significant and clinically significant? The results should be both statistically significant (with a p-value <0.05) and clinically significant using some measure of Effect Size such as Standardized Mean Difference (e.g., Cohen's d >= 0.33). The summary statistics should report what percentage of the total variance of the dependent variable (e.g., outcome) can be explained by the independent variable (e.g., intervention). In clinical studies, the study should report the number needed to treat for an additional beneficial outcome (NNTB), and the number needed to treat for an additional harmful outcome (NNTH).

        Number Needed To Benefit (NNTB): This is defined as the number of patients that need to be treated for one of them to benefit compared with a control in a clinical trial. (It is defined as the inverse of the absolute risk reduction.) Note: Statistically, the NNTB depends on which control group is used for comparison - e.g., active treatment vs. placebo treatment, or active treatment vs. no treatment.

        Number Needed To Harm (NNTH): This is defined as the number of patients that need to be treated for one of them to be harmed compared with a control in a clinical trial. (It is defined as the inverse of the absolute increase in risk of harm.)

        Tomlinson found “an NNTB of 5 or less was probably associated with a meaningful health benefit,” while “an NNTB of 15 or more was quite certain to be associated with at most a small net health benefit.”

      Ask: Does the researcher accept full responsibility for the study's statistical analysis? The researcher should not just hand over the study's raw data to a corporation (that may have $1,000 million invested in the study) to do the statistical analysis.

    • Completeness of follow-up data:
      Ask: Was the number of withdrawals or dropouts in each group mentioned, and were reasons given for these withdrawals or dropouts? Less than 20% of the research subjects should drop out of the study. The intervention effect should persist over an adequate length of time.

    • Handling of missing data:
      Ask: Was the statistical analysis conducted on the intention-to-treat sample? There must be use of intention-to-treat analysis (as opposed to a completers-only analysis). In this way, all of the research subjects that started the study are included in the final statistical analysis. A completers-only analysis would disregard those research subjects that dropped out.

    • Replication of Findings:
      Ask: Can other researchers replicate this study's results? The research study's methodology should be clearly described so that the study can be easily replicated. The researcher's raw data should be available to other researchers to review (in order to detect errors or fraud).

    • Fraud:
      Ask: Is there a suspicion of fraud? In a research study, examine the independent and dependent variables that are always measured as a positive whole number (e.g., a variable measured on a 5-point Likert-type scale ranging from "1 = definitely false to 5 = definitely true" etc.). For each of these variables, look at their sample size (n), mean (M) and standard deviation (SD) before they undergo statistical analysis. There is a high suspicion of fraud in a study's statistics:

      • If the M is mathematically impossible (online calculator): This is one of the easiest ways to mathematically detect fraud. The mean (M) is defined as "the sum (Sum) of the values of each observation divided by the total number (n) of observations". So: M = Sum/n. Thus: (Sum) = (M) multiplied by (n). We know that, if a variable is always measured as a positive whole number, the sum of these observations always has to be a whole number. For these variables to test for fraud: calculate (M) multiplied by (n). This calculates the Sum which MUST be a positive whole number. If the calculated Sum isn't a positive whole number; the reported mean (M) is mathematically impossible - thus the researcher either cooked the data or made a mistake. A recent study of 260 research papers published in highly reputable psychological journals found that 1 in 2 of these research papers reported at least one impossible value, and 1 in 5 of these research papers reported multiple impossible values. When the authors of the 21 worst offending research papers were asked for their raw data (so that its reliability could be checked) - 57% angrily refused. Yet such release of raw data to other researchers is required by most scientific journals. (Here is an example of a research paper filled with mathematically impossible means.)

      • If the SD is mathematically impossible (online calculator): When researchers fraudulently "cook" their data, they may accidently give their data a mean and standard deviation that is mathematically impossible for a (normally distributed) strictly positive variable (because the "cooked" M and SD would mathematically require the strictly positive variable's range of data to include negative numbers). For a normally distributed sample of size of 25-70, this occurs when the SD is greater than one-half of the M; for a sample size of 70+, this occurs when the SD is greater than one-third of the M [using these formulas].

      • If the SD/M is very small (i.e., the variable's standard deviation is very small compared to the mean suggesting data smoothing).

      • If the SD's are almost identical (i.e., the variables have different means but almost identical standard deviations).

      • If the 4th digit of the values of the variables aren't uniformly distributed - since each should occur 10% of the time (Benford's Law).

      • If the researcher is legally prevented from publishing negative findings about a drug or therapy because that would violate the "nondisclosure of trade secrets" clause in the research contract (i.e., it is a "trade secret" that the drug or therapy is ineffective - hence this can not be "disclosed"). Approximately half of all registered clinical trials fail to publish their results.

      • If the researcher refuses to release his raw data to fellow researchers (so that they can check its validity). In order to be published in most scientific journals, a researcher must promise to share his raw data with fellow researchers. Thus a researcher's refusal to do so is almost a sure indicator of fraud.

      • If the research study's data contradicts the study's own conclusions - surprisingly, this often occurs.

  • Calling Bullshit In The Age of Big Data - "Bullshit is language, statistical figures, data graphics, and other forms of presentation intended to persuade by impressing and overwhelming a reader or listener, with a blatant disregard for truth and logical coherence." Reading the syllabus of this university course should be required reading for every student of mental health. This syllabus is absolutely fantastic!

  • Statistical Methods in Psychology Journals: Guidelines and Explanations - American Psychologist 1999

  • Not All Scientific Studies Are Created Equal - video

  • The efficacy of psychological, educational, and behavioral treatment

  • Estimating the reproducibility of psychological science

  • Psychologists grapple with validity of research

  • Industry sponsorship and research outcome (Review) - Cochrane Library

  • 'We've been deceived': Many clinical trial results are never published - (text and video)

  • Junk science misleading doctors and researchers

  • Junk science under spotlight after controversial firm buys Canadian journals

  • Medicine with a side of mysticism: Top hospitals promote unproven therapies - Are some doctors becoming modern witchdoctors?

  • When Evidence Says No, But Doctors Say Yes


  • Cochrane Collaboration - the best evidence-based, standardized reviews available

Research Topics

Posttraumatic Stress Disorder - Latest Research (2016-2017)


Back to top


Internet Mental Health © 1995-2017 Phillip W. Long, M.D.