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Clinical Care Guideline: Adult Posttraumatic Stress Disorder (PTSD)

Trauma can elicit a range of responses in the brain and the body, both amid the traumatic event and the immediate aftermath. But for some people, symptoms continue long after the traumatic event, or collective events, is over, potentially leading to Posttraumatic Stress Disorder (PTSD). 

 

This care guideline is intended to equip psychiatric providers with a brief summary of the evidenced-based, best-practice knowledge for the effective treatment of PTSD.

Diagnostic Considerations for PTSD in Adults

The criteria below apply to adolescents, children older than 6 years, and adults:

  • Exposure to actual or potential death, serious injury, or sexual violence in one (or more) of the following for more than one month
    • Witnessing events as they occurred to others
    • Directly experiencing the traumatic event(s)
    • Experiencing repeated or extreme exposure to aversive details of traumatic events
    • Learning that the traumatic event(s) occurred to a close family member or friend
  • One or more of the following intrusive symptoms associated with traumatic event(s)
    • Intrusive memories 
    • Physiological reactions to symbols or reminders of the event
    • Recurrent distressing dreams of the traumatic event(s)
    • Dissociative reactions (flashbacks) - depersonalization or derealization
    • Psychological responses to things that symbolize or resemble traumatic events
  • Avoidance of stimuli associated with the traumatic event, as evidenced by one or both of the following
    • Avoidance of reminders (people, places, conversations, activities, objects, situations)
    • Avoidance of memories, thoughts, or feelings about traumatic event
  • Negative alterations in cognition and mood, as evidenced by at least two of the following
    • Blocking out specific aspects of the event(s) (dissociative amnesia)
    • Negative beliefs about themselves or the world (“I am ruined”, “Danger is everywhere”)
    • Detachment from others
    • Loss of interests 
    • Distorted cognitions about the cause of traumatic events can lead to blaming oneself
    • Negative emotional state that doesn't seem to lift (fear, guilt, shame)
    • Difficulty experiencing positive emotions

 

  • Alterations in arousal and reactivity, as evidenced by at least two of the following
    • Irritable or angry behavior
    • Reckless or self-destructive behavior.
    • Hypervigilance/Exaggerated startle response.
    • Difficulty concentrating
    • Poor sleep Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).

 

Have the symptoms negatively impacted the patient’s ability to function in important areas of life, such as in relationships, at work, at school, or complete activities of daily living (such as hygiene, keeping up with responsibilities, etc)?

 

It’s important to note that the above symptoms and experiences may also be attributable to an alternative disorder (such as acute stress disorder or dissociative disorders), a neurological cause, or due to the direct physiologic effects of a substance. As a result, a clinical best practice is to engage in a differential diagnostic assessment before determining if PTSD is the clinically indicated diagnosis. 

 

For complete diagnostic criteria of Adjustment Disorder, consult the Diagnostic and Statistical Manual of Mental Disorders (5th ed., text rev.). American Psychiatric Association. (2022). https://doi.org/10.1176/appi.books.9780890425787

 

When documenting care, be sure to include the specific symptoms of PTSD experienced by the patient. This ensures your note reflects alignment with the diagnosis and demonstrates the medical necessity for the service.  
 

Symptom Screening and Monitoring

The Posttraumatic Stress Disorder Checklist (PCL-5) (1) is a validated, 20-item self-report tool that corresponds to the 20 symptoms listed in DSM-5. It can provide a global assessment of PTSD severity both at the time of diagnosis and throughout treatment. Incorporating routine symptom screening and monitoring is foundational to providing effective care for individuals with PTSD, as it supports accurate diagnoses, defines treatment plan goals based on symptom severity, and guides effective clinical interventions.

 

It is important to consider differential diagnosis when looking at trauma disorders as they can look similar to other mental health disorders. At times, some patients can be diagnosed with bipolar disorder; however, with further detailed assessment, the etiology seems to be trauma-based. For example, extreme fluctuations in mood can be seen with both trauma and bipolar; however, bipolar disorder is an episodic pattern that is not triggered by external factors. The mood symptoms in trauma disorders are more consistent on a day-to-day basis and triggered by traumatic reminders. 

 

At follow-up visits, it is important to ask for improvement in symptoms that the patient was experiencing before seeing if there has been improvement. Also, assessing for any new traumatic events or triggers that may or may not have occurred. 

 

Trauma disorders are often comorbid with substance use disorders. The psychiatry provider needs to screen for substance usage. 

 

When asking patients about trauma, this can be a susceptible topic. Sometimes the patient is unaware of the impact of trauma on their lives. For example, a patient can tell the psychiatric provider that they have not experienced trauma; however, after a few visits, the psychiatric provider learns of neglect and divorce in their childhood. 


It is important to be empathetic and meet patients where they are at. Trauma is defined by the patient, not the psychiatric provider. If the patient feels like something was traumatic, it is important to explore this. 
 

Evidence-Based Approaches to Treatment 

The APA Clinical Practice Guidelines for the Treatment of PTSD (2) strongly recommends the use of the following evidence-based psychotherapies and/or medications for adult patients with PTSD.

Psychotherapy

  • cognitive behavioral therapy (CBT)
  • cognitive processing therapy (CPT)
  • prolonged exposure therapy (PE)
  • eye movement desensitization and reprocessing (EMDR)

 

Before starting trauma-focused treatment, patients should be specifically informed that most (if not all) of the evidence-based psychological treatments involve some degree of direct exposure, with the specific goal of re-processing emotions and cognitions to the point of symptom reduction and remission. In working to achieve this goal, patients might feel worse for a period of time before beginning to feel better, and if feeling worse puts them at risk in any way (i.e., increases their risk of harm to self or others, suicidality, return to substances, etc), adjustments should be made by the therapist regarding the pace or intensity of the treatment, stopping it altogether, or initiating a different treatment. This informed consent about treatment approaches results in shared decision-making between patient and therapist.

Medication

The VA/DoD recommends the following SSRIs for treatment of PTSD:

  • Paroxetine (Paxil)
  • Sertraline (Zoloft)
  • Venlafaxine (Effexor)

 

There isn’t strong evidence for augmentation of SSRIs with PTSD according to the VA/DoD guidelines for PTSD. However, there are times when a psychiatric provider may consider augmentation with Prazosin to help with ongoing nightmares that the patient may be experiencing. There have been some studies showing that Prazosin may be beneficial in treating flashbacks associated with trauma; however, it is important to weigh the risks vs. benefits of this medication.  Also, adjunctive therapies may be considered for psychosis symptoms of PTSD which could include Abilify, Seroquel, Risperidone, etc. Some psychosis symptoms of PTSD can include paranoia and AVH (usually trauma-related or “name” calling). 

 

There is ongoing research on MDMA-assisted psychotherapy. At this time, there isn’t sufficient data to recommend this modality. 

 

Benzodiazepines (such as diazepam and clonazepam) are generally not recommended for the treatment of PTSD due to their high potential for dependence as well as their limited long-term effectiveness. Also, benzodiazepines are contraindicated in PTSD due to increasing symptoms of dissociation. 

 

When deciding what treatment approach to take, it is important to engage in shared decision-making. The psychiatric provider must also be mindful of comorbid conditions that occur most often with PTSD when deciding treatment approach. Some of the most common comorbidities include depression, anxiety, borderline personality disorder and substance use. 
 

Assessing Risk and  Higher Level of Care Needs

Research suggests people with a history of trauma and PTSD have a higher risk of suicidal thoughts, and nearly one in three people with PTSD have reported a suicide attempt. (3) Conducting routine screening of symptom severity, engaging regular assessment of risk, completion of a safety plan, and referral for additional services (such as IOP, PHP, and group therapy) if clinically indicated are all critical components of supporting safety for patients who have experienced trauma. 

 

What if my patient has passive SI and/or chronic SI?

There are times when patients will endorse passive SI and/or chronic SI. It is important to complete the C-SSRS to determine the risk level of the patient, if the patient is not a high risk with active SI, then we can engage the patient in the following ways

  • The first step for a patient who is expressing passive and/or chronic SI is to identify protective factors and future orientation. 
  • Next, we should complete a safety plan in collaboration with the patient. We use the Stanley-Brown Safety Plan that can be found in the AMD note template. It is important to do this with the patient to engage them in their treatment. 
  • It is important to document that a safety plan was completed and patient agrees to safety
  • Sometimes patients may struggle to answer questions on the safety plan including internal coping skills, people they can ask for help when/if a crisis occurs, and/or places that provide distraction. 
    • We can offer coping skills that may be of use i.e. deep breathing, coloring, music, grounding techniques, etc. See what the patient likes to do to help ease their emotions. 
    • Sometimes patients may not have people but have pets that they can go to when in a crisis
  • It is important to assess SI at every follow-up visit as well as going over the safety plan to make adjustments, if needed. 
  • It may be that the patient would benefit from increased therapy sessions. We can collaborate with the therapists by asking the psych support team for their emails. 
  • We may want to see the patients more frequently than every month i.e. every 2 weeks until SI is stable.
  • It is important to ask if the patient is using substances, if they are, it is important to talk about decreasing substance usage as this can increase impulsivity. 
  • If the patient does not have resources or support, it is helpful to connect them to Resources for People who Think About Suicide (and their supporters) | NAMI Massachusetts.

Rula’s team of care coordinators is available to support your client in accessing these additional clinical services outside of Rula. Click here to learn more about how to easily refer your client for a Higher Level of Care (HLOC).


However, if your patient is an acute risk to self or others i.e. active SI with plan, intent, or means then please follow this protocol here. Please reach out to the RNs and Lead NPs to help you in this situation for additional support. 
 

Cultural Considerations

The vulnerability of exposure to traumatic stressors (and increased likelihood of developing PTSD) is often influenced by cultural contexts, including those in poverty or who face stigma and discrimination, homelessness, abuse of all forms, political repression, communal/societal violence, forced immigration, and catastrophic disasters.(4) Additionally, the expression of PTSD symptoms often varies by culture as well and is at risk of misdiagnosis as a result. It is important to always consider the social and cultural contexts of a patient’s treatment needs as part of the diagnostic process. 

 

“When a mental health professional understands the role that culture plays in the diagnosis of a condition and incorporates cultural needs and differences into a person’s care, it significantly improves outcomes.”(5)

 

Tools/Resources:

 

To learn more about children/adolescent treatment in PTSD click here

 

 

References

  1. National Center for PTSD. https://www.ptsd.va.gov/professional/assessment/adult-sr/ptsd-checklist.asp

  2. American Psychological Association. https://www.apa.org/ptsd-guideline/ptsd.pdf

  3. The JED Foundation. https://jedfoundation.org/resource/how-are-trauma-ptsd-and-suicide-linked/

  4. National Institute of Health Ford JD, Grasso DJ, Elhai JD, Courtois CA. Social, cultural, and other diversity issues in the traumatic stress field. Posttraumatic Stress Disorder. 2015:503–46. doi: 10.1016/B978-0-12-801288-8.00011-X. Epub 2015 Aug 7. PMCID: PMC7149881.

  5. National Alliance on Mental Illness (NAMI). (n.d.). Identity and Cultural Dimensions. https://www.nami.org/your-journey/identity-and-cultural-dimensions/ 

  6. VA/DoD Clinical Guidelines for PTSD

https://www.healthquality.va.gov/guidelines/MH/ptsd/VA-DoD-CPG-PTSD-Full-CPG.pdf



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