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This summer – the summer of 2023 – the U.S. Department of Defense (DOD) and Department of Veterans Affairs (VA) published an important document: guidelines for posttraumatic stress disorder (PTSD) treatment for veterans.

This is notable for various reasons.

Primarily, it’s notable because the people who serve in our armed forces are willing to make the ultimate sacrifice for our country, and in many cases, return from their time in the service with physical or mental/emotional pathologies that are a direct result of their service. Therefore, we owe it to them to offer the best treatment and support available.

Next, it’s notable because in 2023, the stigma against acknowledging PTSD symptoms and seeking treatment for PTSD symptoms is slowly fading – and more and more service members are willing to step forward and ask for help.

Finally, it’s notable because there are a host of new approaches to PTSD treatment for veterans, and veterans, their families, and the people who support them need to know what works, what doesn’t, and what the official DOD and VA position is on the various PTSD treatments available to veterans.

To that end, the DOD and VA formed research teams, conducted extensive analyses, and reported their findings in the publication “VA/DOD Clinical Practice Guideline for Management Of Posttraumatic Stress Disorder and Acute Stress Disorder.”

The goals of the guidelines, as elucidated in the publication:

  • Help providers assess patients and collaborate with the patient, family, and any providers to offer the best possible care
  • Emphasize patient-centered care and collaborative decision-making
  • Reduce complications associated with PTSD treatment
  • Promote optimal health outcomes
  • Improve overall quality of life for veterans.

As the title suggests, the guidelines focus on trauma-related pathologies, including post-traumatic stress disorder and acute stress disorder. To understand these diagnoses and their treatment, we’ll start by defining trauma.

What is Trauma?

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR) defines trauma as:

“An event (or series of events) in which an individual has been personally or indirectly exposed to actual or threatened death, serious injury, or sexual violence.”

The VA/DOD guideline describes common psychological reactions to traumatic events:

  • Transient, non-debilitating symptoms
  • Transient, acute stress response (ASR)
  • Acute, time-limited, and clinically significant acute stress disorder (ASD)
  • Persistent disorder, a.k.a. posttraumatic stress disorder (PTSD)
  • PTSD can become chronic if not treated

While most people have heard of PTSD and know what it is, many people have not heard of ASD, which is like PTSD, and shares many of the same symptoms, but does not last as long. Untreated ASD can become PTSD over time, and when PTSD goes untreated, it can become chronic.

We’ll now offer the DSM-V diagnostic criteria for the two trauma-related stress disorders. We’ll begin with acute stress disorder, or ASD.

Diagnosing ASD and PTSD Among Veterans: The First Step Toward Treatment

In mental health treatment, and specifically regarding PTSD and evidence-based treatment for veterans, arriving at an accurate diagnosis is essential. An accurate diagnosis leads to appropriate treatment, which can lead to symptom relief and allow a trauma survivor to get back to life as usual. In contrast, an inaccurate diagnosis – or missed diagnosis – can lead to inappropriate treatment or no treatment at all. This can exacerbate symptoms, prolong the course of a disorder, and cause significant psychological and emotional pain, life disruption, and create vulnerability to symptoms that increase risk of suicidal ideation and/or suicidal behavior.

ASD: Diagnostic Criteria

Category A. Exposure to actual or threatened death, serious injury, or sexual violence:

  • Direct experience of the event(s)
  • Direct witnessing of the event(s)
  • Learning about this type of trauma happening to a loved one.
    • To meet AS criteria, the event(s) must have been violent or accidental.
  • Repeated exposure to details of the event(s)
    • For example, first responders collecting remains, medics documenting events, police examining disturbing evidence, such as that related to child abuse, rape, or assault

Category B. Intrusive Thoughts/Feeling

Intrusion Symptoms

  • Recurring, involuntary, intrusive memories of the event(s) that cause distress
  • Recurring dreams related to the event that cause distress
  • Dissociative reactions, i.e. individual feels or acts as if the traumatic event is happening again.
    • Mild examples include short flashbacks, while extreme examples include losing all connection to the immediate present
  • Intense, persistent psychological distress
  • Intense physiological reactions in response to internal or external cues related to the traumatic event(s)

Negative Mood

  • Persistent inability to experience positive emotions, including:
    • Happiness
    • Satisfaction
    • Love/loving feelings

Dissociative Symptoms

  • Disrupted sense of the reality:
    • Seeing oneself from the outside
    • Feeling/acting dazed
    • Sense of time slowing down
  • Inability to remember the event(s), not caused by amnesia related to brain injury

Avoidance Symptoms

  • Going to extremes to avoid memories connected to the traumatic event(s)
  • Making extreme efforts to avoid reminders of the event(s) – people, places, situations – that elicit powerful, distressing, negative emotions connected to the event(s)

Arousal Symptoms

  • Sleep problems: too little sleep, too much sleep, poor sleep
  • Irritability/anger/outbursts with little cause, often expressed as verbal or physical aggression toward other people, can involve damaging objects/breaking things
  • Hypervigilance: feeling on edge, tense, or on guard all the time
  • Difficulty concentrating
  • Extreme/disproportionate startle response

Category C. Duration of the Disturbance

  • Category B symptoms appear 3 days to 1 month after event(s)
  • Must be present for at least 3 days and up to 1 month

Category D. Disruption

  • Symptoms cause clinically significant distress or impairment in social, occupational, and other critical life domains

Category E. Absence of Alternative Diagnosis/Cause of Symptoms

  • Symptoms and disturbance not explained by medication, alcohol/substance use, or a medical condition such as traumatic brain injury
  • Symptoms and disturbance not explained not better explained as brief psychotic disorder

Those symptoms and symptom categories offer a good idea of what people with ASD experience. The symptom categories and diagnostic criteria for ASD are almost identical for PTSD. Therefore, we won’t share the complete DSM-V criteria for PTSD diagnosis.

Here are the differences:

  • ASD diagnosed only within 1 month of event(s)
  • PTSD diagnosed only when symptoms persist for at least 1 month
  • ASD resolves after one month
  • PTSD does not resolve after one month
  • PTSD symptoms must cause significant distress and impairment
  • Symptoms associated with PTSD may not meet full diagnostic criteria until 6 months after the event(s)
  • For patients with PTSD, negative mood symptoms escalate over time, and can result in:
    • Distortions about the cause/origin of event(s)
    • Inability to remember important details of event(s)
    • Growing self-blame
    • Withdrawal from friends and family
    • Feeling detached/disconnected from people and the world
    • Persistent inability to feel positive emotions
  • For patients with PTSD, symptoms of intrusive thoughts, negative mood, dissociation, arousal, and avoidance last longer than 1 month

The information above offers a sound and comprehensive look at the symptoms and criteria required for a clinical diagnosis of acute stress disorder (ASD) and posttraumatic stress disorder (PTSD). Before we discuss PTSD treatment for veterans, we’ll present the latest prevalence data on PTSD in both the general population and among veterans.

The Prevalence of PTSD: Need for Treatment Among Veterans

We retrieved the following prevalence data from the Wave 3 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC-III)

PTSD in the General Population

  • Lifetime PTSD (any PTSD diagnosis at any time)
    • All adults: 6.1%
    • Women: 8.0%
    • Men: 4.1%
  • Past Year PTSD (diagnosis in past 12 months)
    • All adults: 4.7%
    • Women: 6.1%
    • Men: 3.2%
  • By race/ethnicity:
    • Native Americans showed highest prevalence
    • Whites had higher lifetime and current prevalence than Blacks, Asians and Pacific Islanders, and Hispanics.
    • Differences between Whites, Blacks, and Hispanics were small: around 0.1%-0.2%

Now let’s look at PTSD among service members currently serving.

PTSD Among Active Duty Service Members

  • Post-deployment prevalence:
    • Operation Enduring Freedom (OEF): 13.2% (infantry)
    • Operation Iraqi Freedom (OIF): 13.2% (infantry)
    • OEF and OIF general population post-deployment: 6%
  • Current prevalence:
    • Active military: 10.4%
    • Reserve military: 9.3%
  • Rates of PTSD higher among members of the Army, Navy, and Marine Corps
  • Rates of PTSD lower in the Coast Guard
  • Higher rates reported for non-officers compared to junior, mid-grade, and senior officers
  • Higher rates for women compared with men
  • Rates among older service members high compared to younger service members
  • Higher among LGBT service members compared to non-LGBT service members

That data is for current service members. Next, we’ll look at PTSD among all veterans who are no longer on active duty.

PTSD Among All Veterans

  • Lifetime PTSD:
    • All veterans: 6.9%
  • By gender (lifetime):
    • Women: 13.2%
    • Men: 6.2.%)
  • By age (lifetime):
    • 18-29: 15.3%
    • 30-44: 9.7%
    • 45-64: 8.6%
    • 65+: 3.75%
  • By race/ethnicity (lifetime):
    • Black: 16.7%
    • Hispanic: 17.8%
    • White: 11.1%
  • Past-year PTSD:
    • All veterans: 5.0%
  • By gender (past year):
    • Women: 11.4%
    • Men: 5.2%
  • By race/ethnicity (past year):
    • Black: 10.1%
    • White: 5.9%

To this point, we discussed the definition of trauma, how clinicians diagnose trauma, and the prevalence of trauma among the general civilian population, the active duty military population, and among military veterans. Now we’ll review the types of PTSD treatment for veterans endorsed by the Department of Defense and the Veteran’s Administration.

PTSD Treatment for Veterans: Effective, Evidence-Based Treatment

The guideline publication we introduce in the beginning of this article – VA/DOD Clinical Practice Guideline for Management Of Posttraumatic Stress Disorder and Acute Stress Disorder – is the result of a coordinated effort by the VA and DOD to formalize PTSD diagnosis and treatment among active military service personnel and veterans. The guidelines classified treatment and therapeutic approaches with five categories:

  1. Strong evidence the approach/technique works, called the strong for
  2. Some evidence the approach/technique works, called weak for
  3. Inconclusive/insufficient evidence the approach/technique works, called the neither for or against
  4. Some evidence the approach may exacerbate PTSD, called the weak against
  5. Clear evidence the approach may exacerbate PTSD or cause other problems, called the strong against

Now we’ll review the most common approaches the PTSD treatment for veterans, and include the for/against recommendations, as designated by the Department of Defense and the Veterans Administration.

PTSD Treatment: What Works for Veterans

Psychotherapy:

Psychotherapy refers to what most people think of as one-on-one therapy or counseling.

  • Individual psychotherapy: Strong For
  • Recommended over pharmacologic treatment as a first-line approach
  • Types:
    • Cognitive Processing Therapy: Strong For
    • Eye Movement Desensitization and Reprocessing Therapy: Strong For
    • Prolonged Exposure Therapy: Strong For
    • Ehlers’ Cognitive Therapy for PTSD: Weak For
    • Present-Centered Therapy: Weak For
    • Written Exposure Therapy: Weak For
    • Group Therapy: Neither for Nor Against
    • Couples Therapy: Neither for Nor Against

Pharmacotherapy:

Pharmacotherapy means therapy with medication.

  • Pharmacotherapy: Strong For
  • Recommended after individual psychotherapy
  • Types:
    • Paroxetine: Strong For
    • Sertraline: Strong For
    • Venlafaxine: Strong For
    • Mitriptyline, bupropion, buspirone, citalopram, desvenlafaxine, duloxetine, escitalopram, eszopiclone, fluoxetine, imipramine, mirtazapine, lamotrigine, nefazodone, olanzapine, phenelzine, pregabalin, rivastigmine, topiramate, quetiapine: Neither for Nor Against
    • Psilocybin, ayahuasca, ibogaine, LSD: Neither for Nor Against
    • Divalproex, guanfacine, ketamine, prazosin, risperidone, tiagabine, vortioxetine: Weak Against
    • Benzodiazepines, cannabis, cannabis derivatives: Strong Against

Augmentation Therapy:

Augmentation therapy means a combination of psychotherapy and pharmacotherapy.

  • Psychotherapy + Pharmacotherapy: Neither for Nor Against, overall
  • Types:
    • Aripiprazole, asenapine, brexpiprazole, cariprazine, iloperidone, lumateperone, lurasidone, olanzapine, paliperidone, quetiapine, risperidone, ziprasidone: Weak Against
    • MDMA: Neither for Nor Against

Non-pharmacological Biological Treatments:

The treatments used biological-centered treatment technologies aside from medication.

  • Somatic therapies: Neither for Nor Against
  • Types:
    • Capnometry-assisted respiratory therapy, hyperbaric oxygen therapy, neurofeedback, NightWare©, repetitive transcranial magnetic stimulation (rTMS), stellate ganglion block, or transcranial direct current stimulation (dTMS): Neither for Nor Against
    • Electroconvulsive therapy (ECT), vagus nerve stimulation: Weak Against
    • Mindfulness-Based Stress Reduction (MBSR): Weak For

Complementary, Integrative, and Alternative Approaches:

These are new treatment approaches often called mind-body therapies, experiential therapies, or recreational therapies.

  • Complementary, Integrative, and Alternative Approaches: Neither for Nor Against
  • Types:
    • Yoga, tai chi, chi kung, guided imagery, hypnosis, meditation, relaxation training, mindfulness-based cognitive behavioral therapy (MBCBT): Neither for Nor Against
    • Recreational therapy, exercise, canine or equine therapy, natural experiences (like fishing or hiking): Neither for Nor Against

Technology-Based Treatment:

In this context, technology-based treatment means psychotherapy via video or telephone and/or the use of mobile apps for PTSD treatment for veterans.

  • Technology-based treatment: Strong For
  • Types:
    • HIPAA compliant video: Strong For
    • Telephone: Strong For
    • Mobile Apps: Neither for Nor Against
    • Facilitated internet based cognitive behavioral therapy (CBT): Neither for Nor Against

That’s the end of our review of the VA/DOD assessment of these various approaches to PTSD treatment for veterans. Any veteran, friend of a veteran, or family member of a veteran can use this information as a reference, or click the links and refer to the source information as needed.

How This Study Helps Our Patients

An official government publication like this helps our veteran patients evaluate their options when seeking treatment, support, and care for PTSD. Veterans can read about the treatments, read the DOD/VA assessments and recommendations for, neutral, or against, and discuss the facts with their treatment team.

Then they can create a plan that meets their needs, their personality and preferences, and their overall goals for treatment. That give patients a voice and a choice – also known as agency – in their own healing and recovery process. This is crucial. When a patient feels ownership of the healing process, treatment outcomes improve – and when a patient with PTSD feels safe and secure in the treatment they choose, they increase their chances of treatment success. In this case, treatment success means living the life they want, based on their vision of happiness, free from the recurring, often debilitating symptoms of PTSD.

This is what we want for all our patients – especially our veterans, who made the selfless choice to serve and protect our country.