Posttraumatic Stress Disorder - Foothills Behavioral Health Partners

Posttraumatic Stress Disorder - Foothills Behavioral Health Partners

Posttraumatic Stress Disorder (PTSD) Clinical Guidelines
Developed in collaboration with the mental health centers associated with NBHP and FBHP
DSM-IV-TR Diagnostic Code: 309.81
Diagnostic Considerations:
1. Establish diagnostic accuracy. Key aspects of a PTSD diagnosis include:
 Exposure to a traumatic event, which involves all of the following:
 A perceived threat to one’s own or another’s life or physical integrity
 Response to threat includes intense fear, helplessness, or horror
 Symptoms persist for more than one month following the event.
 Exposure to a traumatic event alone is not sufficient for a diagnosis of PTSD.
 Symptoms must cause significant impairment in functioning and include all three of the
following symptom criteria:
 Re-experiencing the trauma,
 Persistent avoidance of stimuli associated with the trauma
 Symptoms of increased arousal.
2. Consider differential diagnoses including Adjustment Disorder, Mood Disorders, Anxiety
Disorders including specific phobias, and Obsessive-Compulsive Disorder. Rule out Acute Stress
Disorder (ASD) when symptoms resolve within 4 weeks or a V-code diagnosis for transient
symptoms following a traumatic event. Consider organic brain disorder or substance-induced
disorder as a cause of flashback symptoms. Be aware of cultural norms to avoid treating common
behaviors within a particular group as PTSD symptoms, e.g. limited expression of emotion may
be categorized as an avoidance symptom, but is socially appropriate within certain cultures.
3. Clinical assessment can include symptom checklists (PTSD checklist, Davidson Trauma
Scale) or structured diagnostic interviews (Clinician Administered PTSD scale, Structured
Interview for PTSD). Assess risk factors for PTSD including: premorbid mood disorders,
emotional reactivity, stress symptoms, ruminative thinking, extrinsic blame of the event, history
of trauma, or low social support. Use multiple informants, e.g. family or teachers, when
assessing children.
4. Individuals with prolonged or repeated traumatic events may develop additional
symptoms, sometimes called complex PTSD, including: difficulties regulating emotion, identity
development, interpersonal functioning, impulsivity and adaptation. Given this overlap of PTSD
and cluster B personality symptoms assess for personality disorders as a differential or comorbid diagnosis. Conversely, when an individual has a Cluster B personality disorder, a trauma
assessment and screening for PTSD should be considered.
5. When assessing PTSD in children and adolescents, remember the expression of symptoms
may be developmentally influenced. Young children may report generalized fears, e.g. stranger
or separation anxiety, avoidance of situations related to the trauma, or sleep problems.
Elementary-aged children may exhibit posttraumatic reenactment through play, drawings or
verbalizations. They may believe there were omens or warning signs prior to the traumatic event
and can predict and avoid future trauma by paying attention to these signs. Adolescents may
engage in traumatic reenactment by exhibiting impulsive and/or aggressive behaviors.
Treatment Guidelines:
1. Assess regularly for: danger to self or others, depressive symptoms, grief and loss issues,
high-risk behaviors, domestic violence, dissociation, psychotic symptoms, somatization, and
substance use/abuse. It is common for individuals with PTSD to self-medicate with alcohol or
other drugs, which can serve as an avoidance strategy, and impede progress.
Revised 8/1/12
2. Provide psycho-education related to the natural course of PTSD, along with treatment
options. For clients that are continually exposed to trauma because of their work, e.g. military,
police officers, fire fighters, medical personnel, educate about natural reactions to these events,
warning signs for when to seek help, and coping skills. Teach family members how to support
and normalize their family member’s experience.
3. Psychotherapy should begin only after the person has been removed from the crisis situation
and is no longer exposed to trauma. Appropriate training and supervision are necessary when
treating PTSD. Evaluate benefits and possible harm of reprocessing the trauma, recognizing this
may not be advised for a particular client at a particular time. Educate about the potential for
symptoms to increase initially, before alleviating. If the decided course of treatment is
reprocessing the trauma, ensure the client has support mechanisms and coping skills in place to
assist with potential side-effects. Allow the client to control the pace. In addition, address areas
of functioning that can be affected by symptoms of PTSD, such as family and social systems,
work, and/or school.
4. Evidence-based therapies for PTSD include cognitive-behavioral therapy, exposure therapy
and exposure based therapies, such as eye movement desensitization and reprocessing (EMDR),
and stress inoculation training. Children may benefit from interactive therapies such as play
therapy or trauma-focused cognitive behavioral therapy (TF-CBT) (see resources for link to
online course.) Group therapy or support groups may be helpful for clients to share their
struggles and achievements, normalize their experience and manage their current symptoms.
5. Referral to a prescriber for pharmacologic treatment can be helpful in conjunction with
therapy. Medication is not for everyone. Symptoms of PTSD vary, and medication can be helpful
in targeting specific symptoms, such as anxiety, mood, or sleep disturbance.
6. Collaborate with clients and family as partners in recovery. Trauma often affects
relationships with family and friends; for clients with PTSD related to sexual trauma, sexual
relationships can be particularly affected. Teach methods for communicating triggers, symptoms,
and needs, and symptom self-management, including the positive physiological effects of stress
management skills and aerobic exercise on symptoms such as anxiety.
7. Ethnic and cultural factors should be honored during treatment. Work to understand the
social and cultural dynamics of PTSD. Cultural context and the meaning of traumatic events may
affect the development, repression or reduction of symptoms as well as dictating decisions about
whether to take medication or engage in a particular type of therapy. Be cautious when treating
individuals from unfamiliar cultures. Some cultures have different norms and traditions around
death and grief, and individuals can be further traumatized by the actions of well-meaning
outsiders, e.g. in some Native American traditions, you never speak of the dead; discussions
about the deceased must occur indirectly or in the third person.
8. Self-care for therapists is particularly important when working with trauma. Be aware of your
personal reactions to hearing about traumatic events, and attend to signs of secondary trauma.
Obtain consultation, supervision, or your own therapy or support when needed.
Revised 8/1/12
References and Resources for Clinicians
Websites, Articles and Guidelines

American Psychiatric Association: Practice guideline for the treatment of patients with
acute stress disorder and posttraumatic stress disorder.
http://www.pbhcare.org/Guidelines/Guidelines/Blurb/Tree/Adult%20Mental%20Health/
Acute%20Stress%20And%20PTSD/PTSD%20Algorithm.pdf

VA/DoD Clinical practice guideline for the management of post traumatic stress
http://www.healthquality.va.gov/post_traumatic_stress_disorder_ptsd.asp

Foa EB, Davidson JRT, Frances A. The Expert Consensus Guideline Series: Treatment of
Posttraumatic Stress Disorder. J Clin Psychiatry 1999;60
http://www.psychguides.com/sites/psychguides.com/files/docs/ptsdgl.pdf

National Institute for Mental Health: Information on PTSD
http://www.nimh.nih.gov/health/topics/post-traumatic-stress-disorderptsd/index.shtml

Roth, S., Newman, E., Pelcovitz, D., van der Kolk, B., & Mandel, F. S. (1997). Complex
PTSD in victims exposed to sexual and physical abuse: Results from the DSM-IV field
trial for Posttraumatic Stress Disorder. Journal of Traumatic Stress, 10, 539-555.
Treatment Manual for Adult Therapists

Foa, E., Hebree, E. & Rothbaum, B. (2007). Prolonged Exposure Therapy for PTSD:
Emotional Processing of Traumatic Experience. Therapist Guide. Oxford: Oxford
University Press.
Treatment Manuals for Child/Adolescent Therapists

Trauma Focused CBT for children free online course: http://tfcbt.musc.edu/

Cohen, J., Mannarino, A., & Deblinger, E (2006). Treating Trauma and Traumatic Grief
in Children and Adolescents. New York: Guilford Press

Deblinger, A. & Heflinger, A. (1996). Treating Sexually Abused Children and their NonOffending Parents: A Cognitive Behavioural Approach. Thousand Oaks, CA: Sage.
Revised 8/1/12
Posttraumatic Stress Disorder (PTSD): Tips for Recovery
Developed in collaboration with the mental health centers of NBHP and FBHP & the Client and Family Advisory Board
1. Witnessing or experiencing a traumatic event(s) may cause anxiety or panic feelings after the event
as well as a desire to avoid places, people, or things that remind you of the event(s). People with PTSD
may find they are easily startled, think about the event(s) often, have flashbacks where it feels like the
traumatic event is happening in the present, and/or nightmares about the event. If you are experiencing
these symptoms, and they are interfering with your life, you may have posttraumatic stress disorder.
2. Educate yourself about this disorder and actively participate in your treatment. Take an active role
in setting your goals, asking questions about treatment approaches, and setting the pace of treatment. It’s
not unusual to notice an increase in symptoms in the beginning of treatment, as you begin discussing the
trauma. Talk with your therapist about your experience, and ask questions. Ask for resources to learn
more about PTSD (see resource list). Practice the skills you learn in therapy in your daily life.
3. Be aware of triggers in your environment. You may feel, at times, that scary thoughts, images or
memories pop into your head randomly. There is often something in the environment triggering your
reaction, such as a smell, sight, sound or image. Make note of any triggers in your environment so you
can prepare for how to handle them when they arise.
4. Talk about distressing thoughts. It’s normal for people who have experienced trauma to have
distressing thoughts related to the event repeat themselves over and over in their minds. This is normal
and is the brain’s way of trying to make sense or work through what happened. You may have
worrisome thoughts that you will be hurt again or you may worry that you will hurt someone else. It’s
not uncommon to have distressing thoughts about being hurt or hurting others. It’s ok and important to
share these thoughts with your therapist to normalize and work through your experience.
5. Ask for support from people who care about you and who will listen and empathize with your situation.
Talk about your experience only in ways you feel comfortable - such as by talking with family or close
friends, or keeping a journal. Also, let your loved ones know about things that may trigger your
symptoms so that they can support you during those times.
6. Talk to your therapist about if and when a support group may be helpful. Often, members may
have suggestions about how to cope, and many people find it very helpful to know they are not alone in
their experiences.
7. Engage in healthy behaviors to help cope with stress. Eat well-balanced meals, exercise, and get plenty
of rest. Relaxation techniques such as deep breathing, meditation, yoga, visualization or listening to
calm music may help you relax. Remember that alcohol and drug use can worsen symptoms and
interfere with medications. If you use alcohol, use only in moderation. Volunteering or helping others,
even during your own time of distress, can give you a sense of control and can make you feel better
about yourself.
8. Establish or reestablish routines around such things as eating meals, waking and falling asleep,
exercising and engaging in other daily activities at similar times each day. Routines can help create a
sense of normalcy and control.
Revised 8/1/2012
9. If possible, avoid major life decisions such as switching jobs, marital status or place to live until you
are feeling more stable, because these activities will add to your stress.
10. Give yourself time to heal. This may be a difficult time in your life. Allow yourself to mourn any
losses. Try to be patient with changes in your emotions.
Resources for Clients
National Institute for Mental Health, Booklet on Post Traumatic Stress Disorder
http://www.nimh.nih.gov/health/publications/post-traumatic-stress-disorder-ptsd/index.shtml
United States Department of Veterans Affairs: National Center for PTSD Fact Sheet: PTSD in Children
and Adolescents
http://www.ncptsd.va.gov/ncmain/ncdocs/fact_shts/fs_children.html
American Psychiatric Association: Lets Talk Facts about Posttraumatic Stress Disorder
http://www.psychiatry.org/mental-illness/lets-talk-facts-brochures
Mental Health America: Factsheet: Posttraumatic Stress Disorder
http://www.mentalhealthamerica.net/index.cfm?objectid=C7DF91D3-1372-4D20C8E6CFE1B56A38AB
Anxiety Disorders Association of America (ADAA): Brochure on PTSD
http://www.adaa.org/understanding-anxiety/posttraumatic-stress-disorder-ptsd
Expert Consensus Treatment Guidelines for Posttraumatic Stress Disorder: A Guide for Patients and
Families
http://www.psychguides.com/ptsd
Revised 8/1/2012
Consejos prácticos: Trastorno de estrés postraumático (TEPT)
Desarrollado en colaboración con los centros de salud mental de NBHP y FBHP y la Comisión consultiva del consumidor y
asuntos familiares
1. Presenciar o sufrir un(os) evento(s) traumático(s) puede causar sensaciones de ansiedad o de pánico
después del evento tanto como el deseo de evitar lugares, gente, o cosas que le recuerdan del evento (los
eventos). Las personas que padecen de TEPT pueden descubrir que se asusten fácilmente, que piensen
en el evento (los eventos) con frecuencia, que tengan recuerdos recurrentes cuando se sienten como el
evento traumático está ocurriendo de nuevo en el presente, y/o sufrir pesadillas sobre el evento. Si usted
está experimentando estos síntomas, y están entrometiéndose en su vida, es posible que sufra del
trastorno de estrés postraumático.
2. Infórmese acerca de este trastorno y participe activamente en su tratamiento. Tome un papel activo
en el establecimiento de sus metas, haciendo preguntas sobre los enfoques de tratamiento, y fijando el
ritmo de su tratamiento. No es inusual notarse un aumento en los síntomas con el comienzo del
tratamiento, cuando empieza a hablar sobre el trauma. Platique con su terapeuta sobre su experiencia y
haga preguntas. Pida recursos para aprender más sobre el TEPT (véase la lista de recursos). Practique
en la vida diaria las habilidades que aprende durante la terapia.
3. Sea consciente de lo que le provoca en su ambiente. Es posible que en ciertos momentos usted puede
sentir que pensamientos miedosos, imágenes, o recuerdos aparecen de repente en la mente al azar. A
menudo hay algo en el ambiente provocando su reacción, como un olor, algo que ve, un sonido o una
imagen. Tome nota de cualquier cosa en su ambiente que le provoca para poder prepararse en cuanto a
cómo lidiar con ellas cuando surgen.
4. Hable sobre los pensamiento inquietantes. Es normal para la gente que haya sufrido trauma tener
pensamientos inquietantes relacionados al evento que se repiten una y otra vez en su mente. Esto es
normal y es la manera que el cerebro intenta a entender y procesar lo que ocurrió. Quizá tenga
pensamientos preocupantes que usted pueda sufrir daño o hacerle daño a otra persona. No es raro tener
pensamientos inquietantes acerca de sufrir algún daño o hacerle daño a otra persona. Está bien y es
importante compartir estos pensamientos con su terapeuta para normalizarse y buscarle solución a su
experiencia.
5. Pida apoyo a las personas que lo quieren y los que van a escuchar y sentir empatía para su situación.
Hable sobre su experiencia solamente de la manera que se siente cómodo – tal como hablar con su
familia o con buenos amigos, o mantener un diario escrito. También, deje a sus seres queridos saber las
cosas que le pueden provocar sus síntomas para que lo puedan apoyar durante esas épocas.
6. Hable con su terapeuta sobre grupos de apoyo, si le sirvan y cuándo le sirvan. Con frecuencia, los
miembros pueden tener sugerencias sobre cómo salir adelante, y mucha gente lo encuentra útil saber que
no esté sola en las experiencias que tiene.
7. Participe en comportamientos sanos para ayudarle a enfrentarse al estrés. Coma las comidas bien
balanceadas, haga ejercicio, y descanse lo suficiente. Las técnicas de relajamiento como respirar
profundo, meditar, el yoga, la visualización, u oír música calmante pueden ayudarle a relajarse.
Acuérdese que el consumo de alcohol y las drogas ilícitas pueden empeorar los síntomas y obstaculizar
los medicamentos. Si Ud. toma bebidas alcohólicas, hágalo solamente con moderación. Hacerse
Revised 8/1/2012
voluntario para ayudar a los demás, aun durante sus momentos de angustia, le puede dar una sensación
de control y puede hacerse sentir mejor sobre sí mismo.
8. Establezca o restablezca rutinas acerca de actividades como comer, caminar, dormirse, hacer
ejercicio, y hacer otras actividades diarias a más o menos la misma hora cada día. Establecer rutinas le
puede ayudar a crear un sentido de normalidad y control.
9. Cuando sea posible, evite tomar decisiones importantes en la vida como un cambio de trabajo, de su
estado civil, o de su residencia hasta que se sienta más estable, porque estas actividades agregarán a su
estrés.
10. Dese tiempo para sanarse. Puede que éste sea un periodo difícil en su vida. Permítase lamentar cada
pérdida. Trate de tener paciencia con los cambios en sus emociones.
Recursos para clientes
National Institute for Mental Health, Booklet on Post Traumatic Stress Disorder
http://www.nimh.nih.gov/health/publications/post-traumatic-stress-disorder-ptsd/index.shtml
United States Department of Veterans Affairs: National Center for PTSD Fact Sheet: PTSD in Children
and Adolescents
http://www.ncptsd.va.gov/ncmain/ncdocs/fact_shts/fs_children.html
American Psychiatric Association: Lets Talk Facts about Posttraumatic Stress Disorder
http://www.psychiatry.org/mental-illness/lets-talk-facts-brochures
Mental Health America: Factsheet: Posttraumatic Stress Disorder
http://www.mentalhealthamerica.net/index.cfm?objectid=C7DF91D3-1372-4D20C8E6CFE1B56A38AB
Anxiety Disorders Association of America (ADAA): Brochure on PTSD
http://www.adaa.org/understanding-anxiety/posttraumatic-stress-disorder-ptsd
Expert Consensus Treatment Guidelines for Posttraumatic Stress Disorder: A Guide for Patients and
Families
http://www.psychguides.com/ptsd
Revised 8/1/2012