Note: This content is derived from the 2023 VA/DOD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder. For the latest clinical practice guideline for this condition, visit https://www.healthquality.va.gov/guidelines/MH/.
Posttraumatic stress disorder is a mental health condition that can develop after exposure to a traumatic event, such as a serious accident, combat experience, sexual assault, physical abuse, or natural disaster. Many individuals with PTSD repeatedly re-experience the ordeal as flashback episodes, memories, nightmares, or frightening thoughts, especially when exposed to events that remind them of the trauma.
A diagnosis of PTSD requires exposure to a trauma and the presence of symptoms from four different categories:
Intrusive Memories
- Intrusive thoughts
- Distressing dreams
- Flashbacks
- Psychological distress after exposure to traumatic reminders
- Psychological reactivity after exposure to traumatic reminders
Avoidance
- Trauma-related thoughts or feelings
- Trauma-related reminders
Negative Thoughts or Mood
- Inability to recall key features of the trauma
- Overly negative thoughts and assumptions about oneself or the world
- Exaggerated blame of self or others for causing the trauma
- Negative affect
- Decreased interest in activities
- Feeling isolated
- Difficulty experiencing positive affect
Hyperarousal
- Irritability or aggression
- Risky or destructive behavior
- Hypervigilance
- Heightened startle reaction
- Difficulty concentrating
- Difficulty sleeping
PTSD is often comorbid with and shares symptoms common to other conditions, such as substance use disorders, depression, anxiety, chronic health conditions, and sleep difficulties.
PTSD is treatable and many people recover with appropriate treatment. The 2023 VA/DOD Clinical Practice Guideline for the Management of PTSD and Acute Stress Disorder provides guidance relating to screening for PTSD and recommended treatment options. Providers should also stay apprised of the latest Defense Department policy guidance on PTSD. The Psychological Health Center of Excellence has created PTSD clinical support tools for providers, patients, and families based on the guidance in the clinical practice guideline. Additionally, the U.S. Department of Veterans Affairs’ National Center for PTSD offers information and tools to help providers with assessment and treatment of PTSD.
Screening for PTSD
Screening identifies those who exhibit symptoms of PTSD and determines who should receive full evaluation from a trained mental health care provider. The Department of Defense promotes the use of empirically supported screening and assessment procedures, consistent with the 2023 VA/DOD Clinical Practice Guideline for the Management of PTSD and Acute Stress Disorder.
Screening for PTSD in the DOD Health Assessment Forms
The purpose of the Health Assessment Forms is to identify health concerns, including PTSD and other behavioral health conditions that may require referral for additional care and treatment.
Screening for PTSD in Primary Care
The DOD patient-centered medical home initiative includes mandatory annual screening for PTSD (among other mental health conditions) for all beneficiaries of the Military Health System. Primary care offers an ideal setting to educate patients and their families about PTSD and treatment options. Screening for PTSD in primary care may include the Primary Care-PTSD Screen, followed by the PTSD Checklist (PCL) if the PC-PTSD is positive. These measures can assess treatment progress or changes to clinical presentation with repeated administrations.
PTSD Screening Tools
Primary Care-PTSD Screen
The PC-PTSD is a five-item, (yes/no) screening measure for use in primary care. Patients screen positive if they answer “yes” to three or more items and should receive further evaluation for PTSD.
PTSD Checklist for DSM-5 (PCL-5)
The PCL-5 is a 20-item, self-reporting tool using a 0-4 Likert scale, appropriate for use in screening individuals for PTSD, making a provisional PTSD diagnosis, and monitoring PTSD symptom change during and after treatment. It aligns with the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) diagnostic criteria for PTSD. There are three formats: (1) with criterion A component (stressor); (2) without a criterion A component; and (3) with the Life Events Checklist for the DSM-5 (LEC-5) and extended criterion A component.
Treatment for PTSD
According to the 2023 VA/DOD Clinical Practice Guideline for the Management of PTSD and Acute Stress Disorder, both psychotherapy and pharmacotherapy are effective in treating PTSD. When both treatment modalities are available and feasible, it is recommended that indicated psychotherapies are used over the indicated pharmacotherapies. Feasibility determinations should consider the time demands placed on both clinicians and patients.
Psychotherapy for PTSD
The VA/DOD PTSD CPG describes many effective trauma-focused approaches for the treatment of PTSD. The approaches are summarized in the Psychotherapy for Treatment of Posttraumatic Stress Disorder Clinical Support Tool.
Pharmacotherapy for PTSD
The VA/DOD PTSD CPG provides information regarding recommended medications and those not recommended for the treatment of PTSD. Highlights are summarized in the Pharmacologic Interventions for Treating Posttraumatic Stress Disorder (PTSD) Clinical Support Tool.
DOD Policy Guidance on PTSD
DOD-level Policies
PTSD Screening
Military Standards
- DODI 6130.03 Medical Standards for Appointment, Enlistment, or Induction in the Military Services
Establishes medical standards, which, if not met, are grounds for rejection for military service, to include depression
- DODI 6490.07 Deployment-Limiting Medical Conditions for Service Members and DOD Civilian Employees
Establishes policy to ensure that service members and DOD civilian employees deployed and deploying on contingency deployments are medically able to accomplish their duties in deployed environments; and includes specific information on mental health disorders and treatment
- DODI 1332.45 Retention Determinations for Non-Deployable Service Members
Establishes policy, assigns responsibilities, and provides direction for retention determinations for non-deployable service members; provides guidance and instructions for reporting deployability data for the Total Force
- DODI 1332.18 Disability Evaluation System
Establishes policy, assigns responsibilities, and provides procedures for referral, evaluation, return to duty, separation, or retirement of service members for disability in accordance with Title 10, United States Code (U.S.C.)(Reference (c)); and related determinations pursuant to sections 3501, 6303, 8332, and 8411 of Title 5, U.S.C. (Reference (d)); Section 104 of Title 26, U.S.C. (Reference (e)); and section 2082 of Title 50, U.S.C. (Reference (f))
Military Separation
- DODI 1332.14 Enlisted Administrative Separations
Provides policy governing administrative separation of enlisted service members from the military services, and specifically that unless a service member is found fit for duty by the disability evaluation system; a separation for personality disorder, or other mental disorder not constituting a physical disability, is not authorized if service-related PTSD is also diagnosed
Service-specific Policies
Air Force
- AFI 36-3211 Administrative Separation of Airmen
Denotes that an enlisted member must receive a medical examination to assess whether the effects of PTSD or TBI constitute matters in extenuation that relate to the basis for administrative separation.