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Brief Summary

GUIDELINE TITLE

Trauma and post-traumatic stress disorder in patients with HIV/AIDS.

BIBLIOGRAPHIC SOURCE(S)

  • New York State Department of Health. Trauma and post-traumatic stress disorder in patients with HIV/AIDS. New York (NY): New York State Department of Health; 2007 Dec. 8 p. [3 references]

GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Trauma and post-traumatic stress disorder in patients with HIV/AIDS (updated online 2004 Sep). In: Mental health care for people with HIV infection: HIV clinical guidelines for the primary care practitioner. New York (NY): New York State Department of Health; 2001 Mar. p. 69-75.

BRIEF SUMMARY CONTENT

 
RECOMMENDATIONS
 EVIDENCE SUPPORTING THE RECOMMENDATIONS
 IDENTIFYING INFORMATION AND AVAILABILITY
 DISCLAIMER

 Go to the Complete Summary

RECOMMENDATIONS

MAJOR RECOMMENDATIONS

Key Point

Exposure to traumatic events can lead to increased risk-taking behavior, including substance use, unsafe sexual practices, and difficulty forming therapeutic relationships with medical personnel.

Post-Traumatic Stress Disorder (PTSD)

Key Point

The likelihood of a patient developing PTSD varies according to the vulnerability of the affected person and the severity of the stressor.

Diagnosis

The primary care clinician should screen for PTSD annually or more often as clinically indicated.

Clinicians should use the criteria listed in the Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV) for a diagnosis of PTSD in patients with human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) (see table below).

Clinicians should screen patients with PTSD or significant trauma histories for clinical depression, anxiety disorders, or alcohol or other substance use disorders.

Diagnostic Criteria for Post-Traumatic Stress Disorder
  1. The person has been exposed to a traumatic event in which both of the following were present:
    1. The person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death, serious injury, or a threat to the physical integrity of self or others.
    2. The person's response involved intense fear, helplessness, or horror.
  1. The traumatic event is persistently re-experienced in one (or more) of the following ways:
    1. Recurrent and intrusive distressing recollections of the event including images, thoughts, or perceptions
    2. Recurrent distressing dreams of the event
    3. Acting or feeling as if the traumatic event were recurring (e.g., a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur upon awakening or when intoxicated)
    4. Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event
    5. Physiological reactivity upon exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event
  1. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma) as indicated by three (or more) of the following:
    1. Efforts to avoid thoughts, feelings, or conversations associated with the trauma
    2. Efforts to avoid activities, places, or people that arouse recollections of the trauma
    3. Inability to recall an important aspect of the trauma
    4. Markedly diminished interest or participation in significant activities
    5. Feeling of detachment or estrangement from others
    6. Restricted range of affect (e.g., unable to have loving feelings)
    7. Sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span)
  1. Persistent symptoms of increased arousal (not present before the trauma) as indicated by two (or more) of the following:
    1. Difficulty falling or staying asleep
    2. Irritability or outbursts of anger
    3. Difficulty concentrating
    4. Hypervigilance
    5. Exaggerated startle response
  1. Duration of the disturbance (symptoms in criteria B, C, and D) is more than 1 month.
  2. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Key Point

Patients with PTSD may have dissociative symptoms, which may be mistaken for HIV-related dementia or other HIV-related neuropsychiatric disorders.

Management of Survivors of Trauma

Clinicians should refer patients with symptoms of PTSD to a mental health professional as soon as possible for evaluation for psychotherapy or other forms of psychiatric treatment. The goal of treatment should be to reduce symptoms and fully reintegrate a safe sense of self.

If specialized services are unavailable, the primary care clinician should prescribe medications (refer to Appendix XII [see the "Availability of Companion Documents" field]) and monitor the degree of improvement achieved with this strategy alone.

During the acute phase of treatment, clinicians should assess the patient's risk for harm to him/herself or others.

Key Point

Although patients with PTSD may seek help for associated somatic symptoms, they may perceive medical intervention as intrusive and thus re-traumatizing.

Acute Stress Disorder (ASD)

For patients who meet the criteria for ASD, clinicians should follow the same guidelines as those recommended for management of PTSD (see "Management of Survivors of Trauma" section above).

Diagnostic Criteria for Acute Stress Disorder
  1. The person has been exposed to a traumatic event in which both of the following were present:
    1. The person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death, serious injury, or a threat to the physical integrity of self or others
    2. The person's response involved intense fear, helplessness, or horror
  1. Either while experiencing or after experiencing the distressing event, the individual has three (or more) of the following dissociative symptoms:
    1. A subjective sense of numbing, detachment, or absence of emotional responsiveness
    2. A reduction in awareness of his/her surroundings (e.g., "being in a daze")
    3. Derealization
    4. Depersonalization
    5. Dissociative amnesia (i.e., inability to recall an important aspect of the trauma)
  1. The traumatic event is persistently re-experienced in at least one of the following ways:

    Recurrent images, thoughts, dreams, illusions, flashback episodes, or a sense of reliving the experience; or distress on exposure to reminders of the traumatic event

  1. Marked avoidance of stimuli that arouse recollections of the trauma (e.g., thoughts, feelings, conversations, activities, places, people)
  2. Marked symptoms of anxiety or increased arousal (e.g., difficulty sleeping, irritability, poor concentration, hypervigilance, exaggerated startle response, motor restlessness)
  3. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or impairs the individual's ability to pursue some necessary task, such as obtaining necessary assistance or mobilizing personal resources by telling family members about the traumatic experience
  4. The disturbance lasts for a minimum of 2 days and a maximum of 4 weeks and occurs within 4 weeks of the traumatic event
  5. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition, is not better accounted for by brief psychotic disorder, and is not merely an exacerbation of a preexisting Axis I or Axis II disorder

CLINICAL ALGORITHM(S)

None provided

EVIDENCE SUPPORTING THE RECOMMENDATIONS

TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is not specifically stated for each recommendation.

IDENTIFYING INFORMATION AND AVAILABILITY

BIBLIOGRAPHIC SOURCE(S)

  • New York State Department of Health. Trauma and post-traumatic stress disorder in patients with HIV/AIDS. New York (NY): New York State Department of Health; 2007 Dec. 8 p. [3 references]

ADAPTATION

Not applicable: The guideline was not adapted from another source.

DATE RELEASED

2004 Sep (revised 2007 Dec)

GUIDELINE DEVELOPER(S)

New York State Department of Health - State/Local Government Agency [U.S.]

SOURCE(S) OF FUNDING

New York State Department of Health

GUIDELINE COMMITTEE

Mental Health Committee

COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

Chair: Milton L Wainberg, MD, New York State Psychiatric Institute, New York, New York

Members: Bruce D Agins, MD, MPH, New York State Department of Health AIDS Institute, New York, New York; Kalyana Battu, MD, Albany Medical Center, Albany, New York; Barbara A Conanan, RN, MS, Saint Vincent's Manhattan Department of Community Medicine, New York, New York; Joseph Z Lux, MD, Bellevue Hospital, New York, New York; Peter Meacher, MD, AAHIVS, FAAFP, South Bronx Health Center for Children and Families, Bronx, New York; Yiu Kee Warren Ng, MD, New York Presbyterian Hospital, Columbia University Medical Center, New York, New York; Bella M Schanzer, MD, MPH, Columbia University Medical Center, New York, New York

Liaisons: Francine Cournos, MD, Liaison to the New York/New Jersey AIDS Education and Training Center, Columbia University, New York State Psychiatric Institute, New York, New York; James J Satriano, PhD, Liaison to the New York State Office of Mental Health, Columbia University College of Physicians and Surgeons, New York, New York

AIDS Institute Staff Liaison: L Jeannine Bookhardt-Murray, MD, Harlem United Community AIDS Center, New York, New York

AIDS Institute Representative: Heather A Duell, LMSW, New York State Department of Health AIDS Institute, Bureau of Community and Support Services, Albany, New York

FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Trauma and post-traumatic stress disorder in patients with HIV/AIDS (updated online 2004 Sep). In: Mental health care for people with HIV infection: HIV clinical guidelines for the primary care practitioner. New York (NY): New York State Department of Health; 2001 Mar. p. 69-75.

GUIDELINE AVAILABILITY

AVAILABILITY OF COMPANION DOCUMENTS

The following are available:

This guideline is also available as a Personal Digital Assistant (PDA) download from the New York State Department of Health AIDS Institute Web site.

PATIENT RESOURCES

None available

NGC STATUS

This NGC summary was completed by ECRI on May 5, 2005. This summary was updated by ECRI on August 15, 2005, following the U.S. Food and Drug Administration advisory on antidepressant medications. This summary was updated by ECRI on August 15, 2005, following the U.S. Food and Drug Administration advisory on antidepressant medications. This summary was updated by ECRI on October 3, 2005, following the U.S. Food and Drug Administration advisory on Paxil (paroxetine). This summary was updated by ECRI on December 12, 2005, following the U.S. Food and Drug Administration advisory on Paroxetine HCL - Paxil and generic paroxetine. This summary was updated by ECRI on May 31, 2006 following the U.S. Food and Drug Administration advisory on Paxil (paroxetine hydrochloride). This NGC summary was updated by ECRI Institute on June 6, 2008.

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