Clinical Care Guideline: Posttraumatic Stress Disorder (PTSD)

Trauma can elicit a range of responses in the brain and the body, both in the midst of 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 or PTSD. 

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

Diagnostic Considerations for PTSD in Adults

As a result of exposure to a traumatic event, or repeated events, is your client experiencing:

• Intrusive memories or flashbacks
• physiological reactions to symbols or reminders of the event
• avoidance of reminders (people, places, conversations, activities, objects, situations)
• Blocking out specific aspects of the event(s) (dissociative amnesia)
• Negative beliefs about themselves or the world (“I am ruined”, “Danger is everywhere”)
• Detachment or loss of interest
• Negative emotional state that doesn't seem to lift (fear, guilt, shame) and difficulty experiencing positive emotions
• 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 client’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 prior to determining if PTSD is the clinically indicated diagnosis. 

For complete diagnostic criteria, 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 the client is experiencing. This ensures your note aligns 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 over the course of 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.

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 clients with PTSD.

Psychotherapy

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

Prior to starting trauma-focused treatment, clients 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, clients 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 client and therapist.

Medication

The APA suggests the following medications (in alphabetical order):

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

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. 

When should I refer my client for psychiatric medication management? 

Clients with PTSD may benefit from discussing the use of medication (in conjunction with continued therapy) with a Psych NP or Psychiatrist to maximize treatment response and symptom reduction. This step-by-step guide walks you through how to easily refer your client for a psychiatric medication management evaluation at Rula.

As a reminder, it is beyond the scope of a psychotherapist to suggest specific medications, groups of medications, specific supplements, or advise on the frequency of taking or stopping medications. These discussions must only be carried out by a medical provider.

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 clients who have experienced trauma.

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).

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 client'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)

Disclaimer: PTSD in Children and Adolescents

This care guideline focuses on best practice guidelines for treating Adults with PTSD, however, PTSD can also present in children and adolescents. Because younger clients cannot always express what they’re experiencing, “classic” symptoms of PTSD may not be as evident. For example, in children, symptoms of PTSD can present as irritability, social withdrawal, nightmares, persistent worry that the world is unsafe, or inability to attach to others.

For information on providing effective care for children and adolescents with PTSD, check out the below resources:

• Practice Parameter for the Assessment and Treatment of Children and Adolescents With Posttraumatic Stress Disorder (Journal of the American Academy of Child and Adolescent Psychiatry) 
• Recognizing and Treating Child Traumatic Stress (SAMHSA)
• PTSD in Children and Teens (National Center for PTSD)

Downloadable Digital Guide

Click HERE for a downloadable digital copy of this guide. 

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/