PRACTICE GUIDELINE FOR THE Treatment of Patients With Acute Stress Disorder and Posttraumatic Stress Disorder WORK GROUP ON ASD AND PTSD Robert J. Ursano, M.D., Chair Carl Bell, M.D. Spencer Eth, M.D. Matthew Friedman, M.D., Ph.D. Ann Norwood, M.D. Betty Pfefferbaum, M.D., J.D. Robert S. Pynoos, M.D. Douglas F. Zatzick, M.D. David M. Benedek, M.D., Consultant Originally published in November 2004. A guideline watch, summarizing significant developments in the scientific literature since publication of this guideline, may be available in the Psychiatric Practice section of the APA web site at www.psych.org. This guideline is dedicated to Rebecca M. Thaler Schwebel (1972–2004), Senior Project Manager at APA when this guideline was initiated. Becca’s humor, generous spirit, and optimism will be missed. 1 AMERICAN PSYCHIATRIC ASSOCIATION STEERING COMMITTEE ON PRACTICE GUIDELINES John S. McIntyre, M.D., Chair Sara C. Charles, M.D., Vice-Chair Daniel J. Anzia, M.D. Ian A. Cook, M.D. Molly T. Finnerty, M.D. Bradley R. Johnson, M.D. James E. Nininger, M.D. Paul Summergrad, M.D. Sherwyn M. Woods, M.D., Ph.D. Joel Yager, M.D. AREA AND COMPONENT LIAISONS Robert Pyles, M.D. (Area I) C. Deborah Cross, M.D. (Area II) Roger Peele, M.D. (Area III) Daniel J. Anzia, M.D. (Area IV) John P. D. Shemo, M.D. (Area V) Lawrence Lurie, M.D. (Area VI) R. Dale Walker, M.D. (Area VII) Mary Ann Barnovitz, M.D. Sheila Hafter Gray, M.D. Sunil Saxena, M.D. Tina Tonnu, M.D. STAFF Robert Kunkle, M.A., Senior Program Manager Amy B. Albert, B.A., Assistant Project Manager Laura J. Fochtmann, M.D., Medical Editor Claudia Hart, Director, Department of Quality Improvement and Psychiatric Services Darrel A. Regier, M.D., M.P.H., Director, Division of Research 2 APA Practice Guidelines CONTENTS Statement of Intent. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Guide to Using This Practice Guideline . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Development Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Part A: Treatment Recommendations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11 I. Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 A. Coding System. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 B. Summary of Recommendations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 II. Formulation and Implementation of a Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 A. Initial Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 B. Principles of Psychiatric Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 C. Principles of Treatment Selection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 D. Specific Treatment Strategies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 III. Specific Clinical Features Influencing the Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 A. Age . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 B. Gender . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 C. Ethnic and Cross-Cultural Factors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 D. Medical and Other Psychiatric Comorbidity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 E. History of Previous Traumas. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 F. Aggressive Behavior. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 G. Self-Injurious and Suicidal Behaviors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 Part B: Background Information and Review of Available Evidence . . . . . . . . . . . . . . . .39 IV. Disease Definition, Epidemiology, and Natural History. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 A. Core Clinical Features. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 B. Associated Features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 C. Differential Diagnosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 D. Epidemiology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 E. Natural History and Course. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 V. Review and Synthesis of Available Evidence. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 A. Issues in Interpreting the Literature. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 B. Psychosocial Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 C. Pharmacotherapies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63 Part C: Future Research Needs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .67 Individuals and Organizations That Submitted Comments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71 Treatment of Patients With Acute Stress Disorder and Posttraumatic Stress Disorder 3 STATEMENT OF INTENT The American Psychiatric Association (APA) Practice Guidelines are not intended to be con- strued or to serve as a standard of medical care. Standards of medical care are determined on the basis of all clinical data available for an individual patient and are subject to change as sci- entific knowledge and technology advance and practice patterns evolve. These parameters of practice should be considered guidelines only. Adherence to them will not ensure a successful outcome for every individual, nor should they be interpreted as including all proper methods of care or excluding other acceptable methods of care aimed at the same results. The ultimate judgment regarding a particular clinical procedure or treatment plan must be made by the psy- chiatrist in light of the clinical data presented by the patient and the diagnostic and treatment options available. This practice guideline has been developed by psychiatrists who are in active clinical prac- tice. In addition, some contributors are primarily involved in research or other academic endeavors. It is possible that through such activities some contributors, including work group members and reviewers, have received income related to treatments discussed in this guide- line. A number of mechanisms are in place to minimize the potential for producing biased recommendations due to conflicts of interest. Work group members are selected on the basis of their expertise and integrity. Any work group member or reviewer who has a potential con- flict of interest that may bias (or appear to bias) his or her work is asked to disclose this to the Steering Committee on Practice Guidelines and the work group. Iterative guideline drafts are reviewed by the Steering Committee, other experts, allied organizations, APA members, and the APA Assembly and Board of Trustees; substantial revisions address or integrate the com- ments of these multiple reviewers. The development of the APA practice guidelines is not financially supported by any commercial organization. More detail about mechanisms in place to minimize bias is provided in a document avail- able from the APA Department of Quality Improvement and Psychiatric Services, “APA Guideline Development Process.” This practice guideline was approved in June 2004 and published in November 2004. Treatment of Patients With Acute Stress Disorder and Posttraumatic Stress Disorder 5 GUIDE TO USING THIS PRACTICE GUIDELINE The Practice Guideline for the Treatment of Patients With Acute Stress Disorder and Posttraumatic Stress Disorder consists of three parts (Parts A, B, and C) and many sections, not all of which will be equally useful for all readers. The following guide is designed to help readers find the sections that will be most useful to them. Part A, “Treatment Recommendations,” is published as a supplement to The American Jour- nal of Psychiatry and contains general and specific treatment recommendations. Section I sum- marizes the key recommendations of the guideline and codes each recommendation according to the degree of clinical confidence with which the recommendation is made. Section II pro- vides further discussion of the formulation and implementation of a treatment plan as it applies to the individual patient. Section III, “Specific Clinical Features Influencing the Treatment Plan,” discusses a range of clinical considerations that could alter the general recommendations discussed in Section I. Part B, “Background Information and Review of Available Evidence,” and Part C, “Future Research Needs,” are not included in The American Journal of Psychiatry supplement but are provided with Part A in the complete guideline, which is available in print format, in guideline compendiums, from American Psychiatric Publishing, Inc. (http://www.appi.org), and online through the American Psychiatric Association (http://www.psych.org). Part B provides an over- view of ASD and PTSD, including general information on natural history, course, and epidemi- ology. It also provides a structured review and synthesis of the evidence that underlies the recommendations made in Part A. Part C draws from the previous sections and summarizes areas for which more research data are needed to guide clinical decisions. To share feedback on this or other published APA practice guidelines, a form is available at http://www.psych.org/psych_pract/pg/reviewform.cfm. 6 APA Practice Guidelines DEVELOPMENT PROCESS This practice guideline was developed under the auspices of the Steering Committee on Prac- tice Guidelines. The development process is detailed in a document available from the APA Department of Quality Improvement and Psychiatric Services: the “APA Guideline Develop- ment Process.” Key features of this process include the following: (cid:127) A comprehensive literature review to identify all relevant randomized clinical trials as well as less rigorously designed clinical trials and case series when evidence from randomized trials was unavailable. (cid:127) Development of evidence tables that reviewed the key features of each identified study, including funding source, study design, sample sizes, subject characteristics, treatment characteristics, and treatment outcomes. (cid:127) Initial drafting of the guideline by a work group that included psychiatrists with clinical and research expertise in ASD and PTSD. (cid:127) Production of multiple revised drafts with widespread review; 11 organizations and 55 individuals submitted significant comments. (cid:127) Approval by the APA Assembly and Board of Trustees. (cid:127) Planned revisions at regular intervals. Relevant literature was identified through a computerized search of MEDLINE and the Published International Literature on Traumatic Stress (PILOTS) database, produced by the National Center for Post-Traumatic Stress Disorder and available online (http://www.ncptsd. org//publications/pilots/index.html). An initial search of PubMed was conducted for the peri- od from 1966 to 2002. Key words used were posttraumatic stress, stress disorder, acute stress disorder, posttraumatic stress disorder, and PTSD. Additional citations were identified by us- ing key words emotional trauma, psychic trauma, posttraumatic, disaster, terrorism, rape, as- sault, physical abuse, sexual abuse, childhood abuse, combat, traumatic event, and traumatic incident and then limited to citations that included the key words stress, psychological se- quelae, anxiety, and dissociation. In determining which of the identified citations related to treatment, key words used were treatment, management, therapy, psychotherapy, antidepres- sive agents, tranquilizing agents, anticonvulsants, debriefing, critical incident, eye movement desensitization, and EMDR. Citations were further limited to clinical trials or meta-analyses published in the English language and accompanied by abstracts. A total of 316 citations were found. When applied to the PILOTS database, this search strategy yielded a total of 587 cita- tions, many of which were duplicates of those obtained in the PubMed search. Additional, less formal literature searches were conducted by APA staff and individual work group members. Other published guidelines for the treatment of ASD and PTSD were also reviewed (1, 2). This guideline presents recommendations for the evaluation and treatment of adult patients with ASD or PTSD. The Practice Parameters for the Assessment and Treatment of Children and Adolescents With Posttraumatic Stress Disorder of the American Academy of Child and Adoles- cent Psychiatry (3) may be consulted for guidelines relating to the evaluation and treatment of children and adolescents. This document represents a synthesis of current scientific knowledge and rational clinical practice. It strives to be as free as possible of bias toward any theoretical approach to treatment. Articles identified in the initial literature search were prioritized for review according to meth- Treatment of Patients With Acute Stress Disorder and Posttraumatic Stress Disorder 7 odological strength. Highest priority was given to randomized, placebo-controlled trials of psy- chotherapeutic and psychopharmacological interventions for individuals with a diagnosis of ASD or PTSD. The work group review process identified further citations that included ran- domized and open trials, literature reviews, meta-analyses, and other studies that were incor- porated into evidence tables in an iterative manner. In interpreting the conclusions of these studies, consideration was given to factors that could limit the generalizability of the findings, including differences between individuals enrolled in well-controlled efficacy trials and indi- viduals seen in clinical practice. Consequently, the recommendations for any particular clinical decision are based on the best available data and clinical consensus. The summary of treatment recommendations is keyed according to the level of confidence with which each recommenda- tion is made. In addition, each reference is followed by a letter code in brackets that indicates the nature of the supporting evidence. 8 APA Practice Guidelines INTRODUCTION It has long been recognized that stressful life events may cause emotional and behavioral effects. In addition, the clinical phenomenon of PTSD has been known by various names, studied, and treated for centuries. In 1980, DSM-III delineated distinct criteria for the diagnosis of PTSD. The diagnosis of ASD was added to DSM-IV in 1995 to distinguish individuals with PTSD- like symptoms that lasted less than 1 month from persons who experienced milder or more transient difficulties following a stressor. The DSM-IV-TR diagnostic criteria for both disor- ders can be found in Section II.A.2. Although 50% to 90% of the population may be exposed to traumatic events during their lifetimes (4, 5), most exposed individuals do not develop ASD or PTSD. ASD was introduced into DSM in an effort to prospectively characterize the subpopulation of traumatically exposed persons with early symptoms and identify those at risk for the development of PTSD. Research and clinical experience show that those with high levels of symptoms early on, including those with ASD, are at risk of subsequent PTSD; however, some patients with ASD do not develop PTSD, and a proportion of patients develop PTSD without first having met the criteria for ASD (6–8). Although research shows that individuals who are most highly exposed to a trau- matic event are at greatest risk, there is still uncertainty about the patient- or trauma-specific factors that will predict the development of ASD (9) and about interventions that will mitigate against the evolution of ASD into PTSD. The lifetime prevalence of ASD is unclear, but in the National Comorbidity Survey the es- timated lifetime prevalence of PTSD was 7.8% (4). The prevalence of both disorders is consid- erably higher among patients who seek general medical care (10) and among persons exposed to sexual assault (4, 5) or mass casualties such as those occurring in wars or natural disasters (11–13). The lifetime prevalence of PTSD is also higher in women than in men and is higher in the presence of underlying vulnerabilities such as adverse childhood experiences or comorbid diagnoses (11, 12, 14, 15). Given the prevalence of ASD and PTSD and their associated dis- tress and disability, psychiatrists must be prepared to recognize and treat these disorders. Treatment of Patients With Acute Stress Disorder and Posttraumatic Stress Disorder 9