Preventing post-disaster PTSD: Watch for autonomic signs

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Posttraumatic stress disorder (PTSD) is underdiagnosed among combat-exposed individuals and overdiagnosed among civilians. An expanded, nondichotomous checklist of emotional and physical signs following a disaster may help address this problem.

PTSD diagnostic criteria shortcomings

Schnurr et al calculated that DSM-IV-TR diagnostic criteria A1 and A2 for PTSD together have a 34% positive predictive value when applied to victims of violent crime.1 Many who meet these criteria may not need intervention, and some interventions—such as critical incident stress debriefing—may be detrimental.2,3

DSM-IV criteria A1 and A2 do not take into account common peritraumatic autonomic activation signs—shortness of breath, tremulousness, racing heart, and sweaty palms/cold sweat—that are part of the human hardwired acute response to threat.4 Last year we published a research checklist of criteria A1 and A2 symptoms plus the four autonomic signs, which we collectively refer to as “criterion A3.”4

A preliminary (tentatively weighted) clinical version of this checklist, the PTSD Criterion A3 Checklist (Table), may be useful for screening persons in the acute aftermath of a disaster. While more research is needed, this version is:


PTSD Criterion A3 Checklist

Incident:Total score*
Time since incident: ________________
At the time, did you…Points for “Yes” answers
Criterion A1
That you would be seriously physically injured or killed?4Total
A1 score:
That a close family member would be seriously physically injured or killed?3
That someone else would be killed?1
Criterion A2
Intense fear or fright?1Total
A2 score:
Criterion A3
(Proposed for DSM-V)
Shortness of breath?1Total
A3 score:
Trembling, shaking or buckling knees?1
Racing/pounding heart?1
Sweaty palms or other cold sweat?1
• Consider preventive intervention (eg, propranolol regimen) if total score is 5 or more.

Fear-specific. The checklist includes queries about two peritraumatic, fear-specific signs (tremulousness and sweaty palms/cold sweat) as well as peritraumatic tachycardia and dyspnea.

Brief. This tool takes as little as 2 minutes to administer, thus minimizing the burden on victims in the days or weeks after a mass disaster.

Non-dichotomous but easy to score. One point is scored for each “Yes” answer for 8 of the 10 queries; “Yes” answers to the two other queries are worth 4 and 3 points, respectively. A total score of 5 or more may indicate a need for preventive intervention such as propranolol, 40 mg tid or qid for 7 to 10 days.5,6

Minimizes stigma. Assessing peritraumatic physical signs may help minimize stigma-related bias.4 This is important when screening persons likely to underreport criterion A2 symptoms, including:

  • veterans
  • military personnel
  • firefighters
  • police officers
  • men in general
  • persons from ethnic cultures in which having psychiatric symptoms is viewed as disgraceful.

Easy to remember. After a few administrations, the queries can be easily memorized and incorporated into initial assessments. The four acute autonomic activation signs can be remembered with the acronym “STRS” (shortness of breath, trembling, racing heart, sweaty palms). Consider “A3” a mnemonic for “acute autonomic activation.”

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