Guideline sources The following summarized guidelines for the evaluation and management of posttraumatic stress disorder (PTSD) are prepared by our editorial team based on guidelines from the Canadian Expert Group on Cannabinoids Use in Chronic Pain (CCP-CEG 2023), the American Psychiatric Association (APA 2019), the Ontario Neurotrauma Foundation (ONF 2018), the United States Department of Defense (DoD/VA 2017), and the Anxiety Disorders Association of Canada (ADAC 2014). 1 2 3 4 5 6 7 8 8 8 Definition PTSD is a mental disorder resulting from exposure to a traumatic experience, which is typically characterized by intrusive, involuntary, and/or distressing recollection or re-experience of the traumatic events. 6 Epidemiology PTSD is caused by traumatic exposure to death, injury, sexual assault, torture, or bodily disfigurement. 8 Pathophysiology https://web.pathway.md/diseases/recfRWmweKSu98c3M 1/6 6/29/23, 11:24 PM Posttraumatic stress disorder Pathway In the United States, the estimated prevalence of PTSD, based on the Same Event definition of DSM-V for lifetime, past-12-month, and past 6-month is 8.3%, 4.7%, and 3.8%, respectively. 7 Disease course The psychological impact of trauma leads to abnormalities in fear learning, threat detection, executive function, emotion regulation, and contextual processing. These neuroendocrine changes are linked to altered activity in the amygdala. PTSD is associated with mood, anxiety, substance abuse disorders, or suicidal ideation leading to serious disability, medical illness, and premature death. The relative risk of suicidal ideation in PTSD is similar to the relative risk of GAD or alcohol dependence; however, is lower than that of depression. 8 8 Guidelines 1. Screening and diagnosis Indications for screening: consider obtaining periodic screening for PTSD using validated measures such as the Primary Care PTSD Screen or PTSD Checklist. C 2. Diagnostic investigations Clinical evaluation: Obtain appropriate diagnostic evaluation in patients with suspected PTSD including: determination of DSM criteria assessment of acute risk of harm to self or others functional status medical history past treatment history relevant family history. A Show 3 more 3. Medical management General principles: engage patients in shared decision making and educate them about effective treatment options. A Show 2 more Antidepressants: As per APA 2019 guidelines: Consider offering fluoxetine, paroxetine, sertraline, or venlafaxine in adult patients with PTSD. C Offer either venlafaxine ER or sertraline when both are considered in adult patients with PTSD. A https://web.pathway.md/diseases/recfRWmweKSu98c3M 2/6 6/29/23, 11:24 PM Posttraumatic stress disorder Pathway As per VA 2017 guidelines, offer sertraline, paroxetine, fluoxetine or venlafaxine as monotherapy in patients with PTSD choosing not to engage in or are unable to access trauma-focused psychotherapy. A Show 4 more As per ADAC 2014 guidelines, offer fluoxetine, paroxetine, sertraline, or venlafaxine XR as first-line therapy in patients with PTSD. A Show 5 more Antipsychotics: As per APA 2019 guidelines, insufficient evidence to recommend for or against the use of risperidone in adult patients with PTSD. I As per VA 2017 guidelines, do not use risperidone as monotherapy in patients with PTSD. D Show 2 more As per ADAC 2014 guidelines, offer risperidone as second-line adjunctive therapy in patients with PTSD. A Show 3 more Anticonvulsants: As per APA 2019 guidelines, insufficient evidence to recommend for or against the use of topiramate in adult patients with PTSD. I As per VA 2017 guidelines, do not use divalproex or tiagabine as monotherapy in patients with PTSD. D Show 3 more As per ADAC 2014 guidelines, offer topiramate A , lamotrigine B , or carbamazepine as third-line therapy in patients with PTSD. B Show 3 more Other medications: As per VA 2017 guidelines, do not use guanfacine, benzodiazepines, ketamine, hydrocortisone, or D-cycloserine as monotherapy in patients with PTSD. D Show 7 more As per ADAC 2014 guidelines, offer buspirone or memantine as third-line therapy in patients with PTSD. B Show 2 more Other medications (CEG-CCP): offer cannabinoid-based medicines to improve PTSD symptoms in patients with chronic pain not responsive to, or intolerant of, nonpharmacologic treatment. B Combination therapy: insufficient evidence to recommend for or against augmentation with pharmacotherapy in partial- or non-responders to psychotherapy. Show 2 more 4. Nonpharmacologic interventions Psychotherapy: https://web.pathway.md/diseases/recfRWmweKSu98c3M 3/6 6/29/23, 11:24 PM Posttraumatic stress disorder Pathway As per APA 2019 guidelines, offer one of the following psychotherapies/interventions (listed alphabetically) in adult patients with PTSD: CBT cognitive processing therapy cognitive therapy prolonged exposure therapy. A Show 6 more As per VA 2017 guidelines, offer individual, manualized trauma-focused psychotherapy over other pharmacologic and nonpharmacologic interventions for the primary treatment of patients with PTSD. A Show 9 more Alternative and complementary therapies: As per VA 2017 guidelines: Insufficient evidence to recommend acupuncture as a primary treatment in patients with PTSD. Insufficient evidence to recommend any complementary or integrative health practice, such as meditation (including mindfulness), yoga, or mantram meditation, as a primary treatment in patients with PTSD. I 5. Therapeutic procedures Therapies with no evidence for benefit: as per VA 2017 guidelines, insufficient evidence to recommend for or against the following therapies in patients with PTSD: repetitive transcranial magnetic stimulation electroconvulsive therapy hyperbaric oxygen therapy stellate ganglion block vagal nerve stimulation. I 6. Specific circumstances Patients after traumatic brain injury: assess for symptoms of PTSD in the assessment of common post-concussive mental health symptoms in patients after concussion. B Show 4 more 7. Preventative measures Prevention after acute stress: offer individual trauma-focused psychotherapy including a primary component of exposure and/or cognitive restructuring for the indicated prevention of PTSD in patients with acute stress disorder. A Show 2 more https://web.pathway.md/diseases/recfRWmweKSu98c3M 4/6 6/29/23, 11:24 PM Posttraumatic stress disorder Pathway Clinical findings Symptoms Past medical history Anxiety Depression Emotional lability Substance use disorder Fear Traumatic injury Flashbacks Social history Irritability Loss of appetite Disaster survival Memory impairment Exposure to A dangerous event Mood changes Veteran Nightmares Sleeping disorder Suicidal ideation Trouble concentrating Past events Experienced or witnessed a life- threatening trauma Studies 2021 MAPP1 In patients with severe posttraumatic stress disorder, including those with common comorbidities such as dissociation, depression, a history of alcohol and substance use disorders, and childhood trauma, MDMA-assisted therapy was superior to placebo with therapy with respect to reduction in posttraumatic stress disorder symptoms, as measured by the Clinician-Administered PTSD Scale for DSM-5 at 18 weeks. Jennifer M Mitchell et al. Nat Med. 2021 Jun. 2019 ICU-diary In adult patients (with 1 family member each) who received mechanical ventilation within 48 hours after ICU admission for at least 2 days, intervention was not superior to control with respect to significant posttraumatic stress disorder symptoms. Mait Garrouste-Orgeas et al. JAMA. 2019 Jul 16. References 1. The Management of Posttraumatic Stress Disorder Work Group. VA/DOD CLINICAL PRACTICE GUIDELINE FOR THE MANAGEMENT OF POSTTRAUMATIC STRESS DISORDER AND ACUTE STRESS DISORDER. Version 3.0 2017. Open 2. Alan D Bell, Caroline MacCallum, Shari Margolese et al. Clinical Practice Guidelines for Cannabis and Cannabinoid-Based Medicines in the Management of Chronic Pain and Co-Occurring Conditions. https://web.pathway.md/diseases/recfRWmweKSu98c3M 5/6 6/29/23, 11:24 PM Posttraumatic stress disorder Pathway Cannabis Cannabinoid Res. 2023 Mar 27. Open 3. Katzman MA, Bleau P, Blier P et al. Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders. BMC Psychiatry. 2014;14 Suppl 1 S1. Open 4. Guideline Development Panel for the Treatment of PTSD in Adults, American Psychological Association. Summary of the clinical practice guideline for the treatment of posttraumatic stress disorder PTSD in adults. Am Psychol. Jul-Aug 2019;74 5 596 607. Open 5. Gioia GA, Collins M, Isquith C et al. Guideline for Concussion/Mild Traumatic Brain Injury & Persistent Symptoms. Ontario Neurotrauma Foundation. Open 6. Goldstein RB, Smith SM, Chou SP et al. The epidemiology of DSM 5 posttraumatic stress disorder in the United States: results from the National Epidemiologic Survey on Alcohol and Related Conditions-III. Soc Psychiatry Psychiatr Epidemiol. 2016 Aug;51 8 1137 48. Open 7. Kilpatrick DG, Resnick HS, Milanak ME et al. National estimates of exposure to traumatic events and PTSD prevalence using DSM IV and DSM 5 criteria. J Trauma Stress. 2013 Oct;26 5 537 47. Open 8. Shalev A, Liberzon I, Marmar C. Post-Traumatic Stress Disorder. N Engl J Med. 2017 Jun 22;376 25 2459 2469. Open 9. Spoont MR, Williams JW Jr, Kehle-Forbes S et al. Does This Patient Have Posttraumatic Stress Disorder? Rational Clinical Examination Systematic Review. JAMA. 2015 Aug 4;314 5 501 10. Open 10. Bisson JI, Berliner L, Cloitre M et al. ISTSS PTSD Prevention and Treatment Guidelines Methodology and Recommendations. International Society for Traumatic Stress Studies. 2019. J Trauma Stress. 2019 Aug;32 4 475 483. Open 11. William P Nash, Patricia J Watson. Review of VA/DOD Clinical Practice Guideline on management of acute stress and interventions to prevent posttraumatic stress disorder. J Rehabil Res Dev. 2012;49 5 637 48. Open 12. Jennifer M Mitchell, Michael Bogenschutz, Alia Lilienstein et al. MDMA-assisted therapy for severe PTSD a randomized, double-blind, placebo-controlled phase 3 study. Nat Med. 2021 Jun;27 6 1025 1033. Open 13. David S Baldwin, Ian M Anderson, David J Nutt et al. Evidence-based pharmacological treatment of anxiety disorders, post-traumatic stress disorder and obsessive-compulsive disorder: a revision of the 2005 guidelines from the British Association for Psychopharmacology. J Psychopharmacol. 2014 May;28 5 403 39. Open https://web.pathway.md/diseases/recfRWmweKSu98c3M 6/6