Management of PostTraumatic Stress Disorder and Acute Stress Disorder

Publication Date: July 1, 2023
Last Updated: July 17, 2023

Assessment and Diagnosis of PTSD

When screening for PTSD, we suggest using the Primary Care PTSD Screen for DSM-5. (Weak for)
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For confirmation of the diagnosis of PTSD, we suggest using a validated structured clinician-administered interview, such as the Clinician-Administered PTSD Scale or PTSD Symptom Scale - Interview Version. (Weak for)
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To detect changes in PTSD symptom severity over time, we suggest the use of a validated instrument, such as the PTSD Checklist for DSM-5, or a structured clinician-administered interview, such as the Clinician-Administered PTSD Scale. (Weak for)
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Prevention of PTSD

Selective Prevention of PTSD

For the prevention of PTSD among individuals who have been exposed to trauma, there is insufficient evidence to recommend for or against psychotherapy or pharmacotherapy in the immediate post-trauma period. (Neither for or against)
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Indicated Prevention of PTSD

For the prevention of PTSD among patients diagnosed with acute stress disorder, we suggest trauma-focused cognitive behavioral psychotherapy. (Weak for)
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For the prevention of PTSD among patients diagnosed with acute stress reaction/acute stress disorder, there is insufficient evidence to recommend for or against any pharmacotherapy. (Neither for or against)
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Treatment of PTSD

Treatment Selection

We recommend individual psychotherapies, listed in Recommendation 8, over pharmacologic interventions for the treatment of PTSD. (Strong for)
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Psychotherapy

We recommend the individual, manualized trauma-focused psychotherapies for the treatment of PTSD: Cognitive Processing Therapy, Eye Movement Desensitization and Reprocessing, or Prolonged Exposure. (Strong for)
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We suggest the following individual, manualized psychotherapies for the treatment of PTSD: Ehlers’ Cognitive Therapy for PTSD, Present-Centered Therapy, or Written Exposure Therapy. (Weak for)
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There is insufficient evidence to recommend for or against the following individual psychotherapies for the treatment of PTSD: Accelerated Resolution Therapy, Adaptive Disclosure, Acceptance and Commitment Therapy, Brief Eclectic Psychotherapy, Dialectical Behavior Therapy, Emotional Freedom Techniques, Impact on Killing, Interpersona Psychotherapy, Narrative Exposure Therapy, Prolonged Exposure in Primary Care, psychodynamic therapy, psychoeducation, Reconsolidation of Traumatic Memories, Seeking Safety, Stress Inoculation Training, Skills Training in Affective and Interpersonal Regulation, Skills Training in Affective and Interpersonal Regulation in Primary Care, supportive counseling, Thought Field Therapy, TraumaInformed Guilt Reduction, or Trauma Management Therapy. (Neither for or against)
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There is insufficient evidence to recommend using individual components of manualized psychotherapy protocols over, or in addition to, the full therapy protocol for the treatment of PTSD. (Neither for or against)
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There is insufficient evidence to recommend for or against any specific manualized group therapy for the treatment of PTSD. (Neither for or against)
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There is insufficient evidence to recommend using group therapy as an adjunct for the primary treatment of PTSD. (Neither for or against)
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There is insufficient evidence to recommend for or against the following couples therapies for the treatment of PTSD: Behavioral Family Therapy, Structured Approach Therapy, or Cognitive Behavioral Conjoint Therapy. (Neither for or against)
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Pharmacotherapy

We recommend paroxetine, sertraline, or venlafaxine for the treatment of PTSD. (Strong for)
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There is insufficient evidence to recommend for or against amitriptyline, bupropion, buspirone, citalopram, desvenlafaxine, duloxetine, escitalopram, eszopiclone, fluoxetine, imipramine, mirtazapine, lamotrigine, nefazodone, olanzapine, phenelzine, pregabalin, rivastigmine, topiramate, or quetiapine for the treatment of PTSD. (Neither for or against)
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There is insufficient evidence to recommend for or against psilocybin, ayahuasca, dimethyltryptamine, ibogaine, or lysergic acid diethylamide for the treatment of PTSD. (Neither for or against)
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We suggest against divalproex, guanfacine, ketamine, prazosin, risperidone, tiagabine, or vortioxetine for the treatment of PTSD. (Weak against)
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We recommend against benzodiazepines for the treatment of PTSD. (Strong against)
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We recommend against cannabis or cannabis derivatives for the treatment of PTSD. (Strong against)
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Augmentation Therapy

There is insufficient evidence to recommend for or against the combination or augmentation of psychotherapy (see Recommendation 8 and Recommendation 9) or medications (see Recommendation 15) with any psychotherapy or medication for the treatment of PTSD (see Recommendation 22 for antipsychotic medications and Recommendation 23 for 3,4-methylenedioxymethamphetamine). (Neither for or against)
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We suggest against aripiprazole, asenapine, brexpiprazole, cariprazine, iloperidone, lumateperone, lurasidone, olanzapine, paliperidone, quetiapine, risperidone, or ziprasidone for augmentation of medications for the treatment of PTSD. (Weak against)
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There is insufficient evidence to recommend for or against 3,4-methylenedioxymethamphetamine assisted psychotherapy for the treatment of PTSD. (Neither for or against)
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Non-pharmacologic Biological Treatments

There is insufficient evidence to recommend for or against the following somatic therapies for the treatment of PTSD: capnometry-assisted respiratory therapy, hyperbaric oxygen therapy, neurofeedback, NightWare©, repetitive transcranial magnetic stimulation, stellate ganglion block, or transcranial direct current stimulation. (Neither for or against)
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We suggest against electroconvulsive therapy or vagus nerve stimulation for treatment of PTSD. (Weak against)
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We suggest Mindfulness-Based Stress Reduction® for the treatment of PTSD. (Weak for)
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Complementary, Integrative, and Alternative Approaches

There is insufficient evidence to recommend for or against the following mind-body interventions for the treatment of PTSD: acupuncture, Cognitively Based Compassion Training Veteran version, creative arts therapies (e.g., music, art, dance), guided imagery, hypnosis or self-hypnosis, Loving Kindness Meditation, Mantram Repetition Program, Mindfulness-Based Cognitive Therapy, other mindfulness trainings (e.g., integrative exercise, Mindfulness-Based Exposure Therapy, brief mindfulness training), relaxation training, somatic experiencing, tai chi or qigong, Transcendental Meditation®, and yoga. (Neither for or against)
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There is insufficient evidence to recommend for or against the following interventions for the treatment of PTSD: recreational therapy, aerobic or non-aerobic exercise, animalassisted therapy (e.g., canine, equine), and nature experiences (e.g., fishing, sailing). (Neither for or against)
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Technology-based Treatment

We recommend secure video teleconferencing to deliver treatments in Recommendation 8 and Recommendation 9 when that therapy has been validated for use with video teleconferencing or when other options are unavailable. (Strong for)
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There is insufficient evidence to recommend for or against mobile apps or other self-help-based interventions for the treatment of PTSD. (Neither for or against)
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Treatment of Nightmares

We suggest prazosin for the treatment of nightmares associated with PTSD. (Weak for)
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There is insufficient evidence to recommend for or against the following treatments for nightmares associated with PTSD: Imagery Rehearsal Therapy, Exposure Relaxation and Rescripting Therapy, Imaging Rescripting and Reprocessing Therapy, or NightWare. (Neither for or against)
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Treatment of PTSD with Co-Occurring Conditions

We suggest that the presence of co-occurring substance use disorder and/or other disorder(s) not preclude treatments in Recommendation 8 and Recommendation 9 for PTSD. (Weak for)
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Recommendation Grading

Overview

Title

Management of Posttraumatic Stress Disorder and Acute Stress Disorder

Authoring Organization

Veterans Health Administration / Department of Defense

Publication Month/Year

July 1, 2023

Last Updated Month/Year

January 3, 2024

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Inclusion Criteria

Female, Adult, Older adult

Health Care Settings

Ambulatory, Outpatient

Intended Users

Addiction treatment specialist, nurse, nurse practitioner, physician, physician assistant, psychologist, social worker

Scope

Counseling, Diagnosis, Assessment and screening, Treatment, Management

Diseases/Conditions (MeSH)

D013313 - Stress Disorders, Post-Traumatic

Keywords

behavioral health, Posttraumatic Stress Disorder, Acute Stress Reaction

Methodology

Number of Source Documents
270
Literature Search Start Date
January 1, 2009
Literature Search End Date
March 1, 2022