Post-traumatic stress disorder: clinical guidelines

List of Abbreviations

DBT – dialectical behavior therapy

EMDR – eye movement desensitization and reprocessing

IPP – individual psychological support

IPP-I – informational and psychological support

CBT – cognitive behavioral psychotherapy

PT – physical therapy

ICD – International Classification of Diseases

MRI – magnetic resonance imaging

PAS – psychoactive substances

PTSD – post-traumatic stress disorder

RCTs – randomized clinical trials

rTMS – repetitive transcranial magnetic stimulation

SSRIs – selective serotonin reuptake inhibitors

TF-CBT – trauma-focused cognitive behavioral therapy

Level of Evidence (LoE) – level of certainty of evidence

Grade of Recommendation (GoR) – level of recommendation persuasiveness

EM – emergency situation

EPS – emergency psychological support

** – the drug is included in the list of Vital and Essential Drugs

# – this disease or disorder is not indicated in the instructions for use

Terms and Definitions

Trauma – an event associated with a powerful psychotraumatic impact and accompanied by extreme stress.

Stress – a set of nonspecific adaptive (normal) reactions of the body to the impact of various adverse factors-stressors (physical or psychological) that disrupt its homeostasis, as well as the corresponding state of the body's nervous system (or the body as a whole). In medicine, physiology, and psychology, positive (eustress from Ancient Greek εὖ- "good") and negative (distress from Ancient Greek δύς "loss") forms of stress are distinguished.

Anxiety – a negatively colored emotion expressing a sense of uncertainty, expectation of negative events, and hard-to-define premonitions. Unlike the causes of fear, the causes of anxiety are usually not consciously recognized, but it prevents a person from engaging in potentially harmful behavior or prompts them to take action to increase the likelihood of a successful outcome of events.

Panic attack (panic) – an unpredictable, agonizing attack of severe, pronounced anxiety for the patient, accompanied by fear or apprehension combined with various autonomic (somatic) symptoms.

Psychopharmacotherapy is the use of psychotropic medications in the treatment of mental disorders.

Psychotherapy is a system of therapeutic impact on the psyche, and through the psyche and by means of it, on the entire human body.

Virtual reality (VR, artificial reality) – a world created by technical means and transmitted to a person through their senses of vision, hearing, touch, and others. Virtual reality simulates both the impact and reactions to the impact. To create a convincing complex of reality sensations, computer synthesis of virtual reality properties and reactions is performed in real time.

Intrusion (Late Latin *intrusio* – encroachment, from Latin *intrudo* – to push in) – an invasion, influx, involuntary (uninvited) re-experience of traumatic events, the sensation that the traumatic event is returning as if in reality (in the form of illusions, hallucinations, flashbacks, nightmares) developing through unconscious associative connections and causing severe psychological distress, and may be accompanied by corresponding behavior. Common triggers are circumstances symbolizing or resembling traumatic events (e.g., the anniversary of the trauma, New Year's fireworks for combatants).

Flashback (English) – in common parlance, a return to the past, experiencing feelings, emotions, sensations, or a situation from the past. The term is borrowed from filmmaking, where it denotes a departure from the narrative into the past; the storyline is interrupted, and we observe actions that occurred earlier. Most crops up to explain the actions and deeds of the narrative characters, revealing their thoughts and driving ideas. In psychiatry, a flashback is a dissociative reverse vision, a spontaneous realistic recollection of traumatic events. In addiction medicine, flashbacks manifest as spontaneous short-term relapses of acute intoxication symptoms in the absence of psychoactive substance use.

Exposure – a psychotherapy technique that involves regularly facing one's unpleasant experiences (thoughts, emotions, bodily sensations) – starting with those that cause mild anxiety and gradually moving toward the most difficult to tolerate. Gradual exposure to the problematic conditioned stimulus with prevention of the standard response that provided reinforcement leads to overcoming previously self-reinforced avoidant behavior. The main goal is to prevent avoidance in order to gain experience that anxiety fears are unfounded.

1. Brief information on the disease or condition

1.1 Definition of the disease or condition

Post-traumatic stress disorder (PTSD) is a mental disorder developing as a result of a powerful psychotraumatic impact of a threatening or catastrophic nature, accompanied by extreme stress. Its main clinical manifestations are re-experiences of elements of the traumatic event in the "here and now" situation in the form of flashbacks, recurring dreams and nightmares, which is usually accompanied by anxiety and panic, but may also include anger, rage, a sense of guilt or hopelessness, and a drive to avoid internal and external stimuli resembling or associated with the stressor. Symptoms usually appear within six months of the stress exposure. Triggering factors include events capable of causing distress in almost any person: natural and man-made disasters, threat to life, assault, torture, sexual violence, military operations, terrorist acts, captivity or concentration camp confinement, witnessing the death of another person, a life-threatening illness, or receiving news of the sudden or violent death of a close relative. The disorder is characterized by high comorbidity with other mental disorders and can lead to personality changes [1,2].

1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)

PTSD develops as a result of the individual's inability to cope with an exogenous psychotraumatic impact of an extraordinary nature. Currently, the contribution of genetic factors is being actively investigated, including with the aim of searching for potential new drugs for the treatment of PTSD; to date, there is a large database of genetic studies indicating the polygenic nature of the PTSD phenotype, while the question of the ratio between actual genetic and environmental factors remains open. It is well known that prior trauma increases the risk of developing PTSD, but there is yet no definitive description of the pathogenetic mechanisms of such sensitization [3,4,5,6].

Acute stress reactions are a normal response to extraordinary exposure in a number of individuals. Due to a deficit in adaptability resources, the natural stress response takes on a pathological character; in particular, the functioning of the hypothalamic-pituitary-adrenal axis and the sympathoadrenal system is disrupted, leading to the manifestation of PTSD symptoms, heightened readiness for anxiety reactions, physiological arousal, and hypervigilance [7,8,9,10,11,12,13].

In cognitive models of PTSD, which have currently found confirmation in studies using modern neuroimaging capabilities, the pathogenesis of PTSD is closely linked to impaired information processing and the integration of traumatic experience into the patient's general biographical memory. It was revealed that traumatic memories are associated with reduced activity of the left inferior frontal cortex, which suggests that these memories are dominated by emotional and sensory elements without corresponding linguistic associations.

Information about the trauma remains in active working memory until it is processed. Thus, a cycle of reliving traumatic memories is formed under the influence of triggers associated with the trauma and the drive to avoid unpleasant experiences while trying to control the train of thought and avoid encountering anything that might serve as a reminder of the trauma, which in turn impairs the processing of the traumatic experience. Normally, episodes of intrusive reliving of traumatic experiences alternate with periods of avoidance; over time, as the process concludes, these states become less frequent and less intense. In some cases, a conflict may arise between the need for processing and the existing system of relations, resulting in a conflict followed by the development of avoidant behavior and emotional numbing as manifestations of psychological defense, which paves the way for the subsequent manifestation of comorbid depressive disorders. In such cases, affect loses its signaling function, since any intense emotion is perceived as the danger of a return of the traumatic experience [17,18,19,20].

1.3 Epidemiology of the Disease or Condition

According to international studies, up to 61% of people at various periods of their lives encounter traumatic events that can potentially cause PTSD; however, the disorder manifests only in some of them, with the morbidity rate varying widely from 13% to 50%, depending on individual vulnerability and the nature of the traumatic impact. As a preventive measure against the manifestation of PTSD, it is currently recommended to use therapy only for those trauma-exposed individuals who exhibit trauma- or stress-associated symptoms. Morbidity varies greatly depending on the social context; in favorable periods of societal life, the prevalence of PTSD in the population is 0.5% among men and 1.2% among women. Regarding gender differences, most researchers agree that PTSD is nearly twice as common in women, with the exception of the specific group of combatants. In childhood, conversely, boys appear more vulnerable to the manifestation of PTSD than girls [21,22].

1.4 Features of Coding the Disease or Condition

Coding according to the International Classification of Diseases (ICD-10)

F43.1 — Post-traumatic stress disorder

1.5 Classification of the disease or condition

PTSD in ICD-10

The ICD-10 identifies the following criteria for PTSD:

A. The patient must have been exposed to a stressful event or situation (of either brief or prolonged duration) of an exceptionally threatening or catastrophic nature, which is likely to cause pervasive distress in almost anyone.

B. Persistent recuerring memories or "reliving" of the stressor in intrusive flashbacks, vivid memories, or recurring dreams, or renewed distress when exposed to circumstances resembling or associated with the stressor.

C. The patient must exhibit actual or preferred avoidance of circumstances resembling or associated with the stressor (not observed prior to exposure to the stressor).

D. Either of the following two:

1. psychogenic amnesia (F40.0), either partial or complete, regarding important aspects of the period of stressor exposure;

2. Persistent symptoms of increased psychological sensitivity or arousal (not observed prior to exposure to the stressor), manifested by any two of the following:

a) difficulty falling asleep or staying asleep;

b) irritability or outbursts of anger;

c) difficulty concentrating;

d) hypervigilance;

e) an enhanced startle response.

E. Criteria B, C, and D occur within six months of a stressful situation or at the end of a period of stress (for certain purposes, an onset delayed by more than six months may be included, but these cases must be precisely defined separately).

PTSD in ICD-11

Due to the broad overlap of various PTSD symptom clusters, a low diagnostic threshold, and a high level of comorbidity in the ICD-11 version presented at the World Health Assembly in 2019 in Geneva, changes were proposed to improve the clinical utility of the classification of disorders specifically related to stress.

The first innovation concerns the name of the group of stress-induced disorders. To emphasize the stress situation as a mandatory etiological criterion, ICD-11 introduced the section title "Disorders specifically associated with stress" (L1-6B4) instead of the existing category F43 "Reaction to severe stress and adjustment disorders", which belongs to section F40–F48 "Neurotic, stress-related and somatoform disorders" of ICD-10. This emphasizes that we are dealing exclusively with disorders for which stress is a mandatory and specific cause of development.

The ICD-11 section "Disorders specifically associated with stress" includes adjustment disorder (6B43), PTSD (6B40), and complex PTSD (6B41). In addition, ICD-11 includes a new independent diagnosis: prolonged grief disorder (6B42). The ICD-11 diagnoses of prolonged grief disorder, PTSD, complex PTSD, and adjustment disorder can occur in all age groups, including children and adolescents. This group also includes specific attachment disorders in childhood. Furthermore, acute stress reaction is currently presented as a normal reaction and is therefore classified in the chapter "Factors influencing health status and contact with health services". This category is considered a legitimate target for clinical interventions, but is not defined as a mental disorder [23,24,25,26,27,28,29,30,31].

Key changes in ICD-11:

· a narrower concept of PTSD that prevents making a diagnosis based solely on nonspecific symptoms;

· a new category "complex PTSD", which is equivalent to the diagnosis of "enduring personality change after catastrophic experience" (F62.0 in ICD-10);

· a new diagnosis "prolonged grief disorder", used to characterize patients who experience an intense, painful, disabling, and abnormally persistent response to bereavement;

· a substantial revision of the diagnosis of "adjustment disorder", including the specification of symptoms;

· a revision of the concept of "acute stress reaction" in line with viewing this state as a normal phenomenon which, however, may require clinical intervention.

Classification of PTSD in ICD-11:

1. Post-traumatic stress disorder (6B40)

A disorder that develops following exposure to an extremely threatening or horrifying event or series of events, and is characterized by:

1) re-experiencing the traumatic event(s) in the present in the form of vivid intrusive memories, accompanied by fear or horror, flashbacks, or nightmares;

2) avoidance of thoughts and memories of the event(s), or avoidance of activities or situations reminiscent of the event(s);

3) a state of subjective perception of ongoing threat in the form of hypervigilance or enhanced startle reactions.

Symptoms must last for at least several weeks and cause significant impairment in functioning.

2. Complex post-traumatic stress disorder (6B41)

A disorder that arises following exposure to a stressor of an extreme or prolonged nature, from which escape is difficult or impossible (e.g., exposure to genocide, child sexual abuse, children in war zones, severe domestic violence, torture, or slavery). The disorder is characterized by the core symptoms of PTSD, as well as the development of persistent and pervasive impairments in affect regulation, self-concept, and social functioning, including difficulties in emotion regulation, a sense of being diminished, defeated, or worthless, and difficulties in maintaining relationships.

The diagnosis includes additions to the three typical symptom clusters of PTSD:

1. Persistent long-term disturbances in the affective sphere (increased emotional reactivity, emotional blunting, development of dissociative states);

2. Behavioral disturbances (outbursts of rage, reckless or self-destructive behavior);

3. Alterations in self-concept (persistent negative beliefs about oneself as diminished, defeated, or worthless, which may be accompanied by deep and pervasive feelings of shame, guilt, or failure);

4. Disturbances in social functioning (consistent avoidance of or disinterest in personal relationships and social engagement in general; difficulties in maintaining close relationships).

This model replaces the ICD-10 category "enduring personality change after catastrophic experience" (F62.0).

Comments. In the ICD-11 draft, the authors respond to criticism regarding the excessive complexity and high comorbidity of PTSD by attempting to define the core features of the disorder and make the diagnosis easier to distinguish from other mental disorders. Their goal is to increase clinical utility and prevent overdiagnosis of PTSD by focusing more narrowly on a small set of easily identifiable symptoms. At the same time, pronounced stress-induced changes in personality, affect regulation, and interpersonal functioning are represented in a separate diagnosis of Complex PTSD. It is hoped that the parallel use of the ICD-11-proposed diagnoses of PTSD and Complex PTSD will offer significant advantages for clinicians [28].

It should be remembered that PTSD can develop at any age.

1.6 Clinical presentation of the disease or condition

Clinical manifestation of PTSD occurs as a result of a powerful psychotraumatic impact of a threatening or catastrophic nature, accompanied by extreme stress.

Precipitating factors include events capable of causing distress in almost any person, natural and man-made disasters, threat to life, assault, torture, sexual violence, military operations, terrorist acts, captivity or concentration camp confinement, witnessing the death of another person, life-threatening illness, disabling illness (including trauma, loss of a limb), receiving news of the sudden or violent death of a close relative, etc.

The main criteria for traumatic experiences include:

- The event or situation is of a threatening or catastrophic nature

- The event or situation is capable of causing generalized distress in almost any individual

Thus, two of its features are emphasized: the clearly psychogenic nature of the disorder and the severity of the psychological trauma that goes beyond normal human experience.

The clinical picture of PTSD features the following specific (core) symptoms [1,14,15,16,32,33]:

1. Repeated experiences of the traumatic event (flashbacks presented as intrusive reminiscences, vivid intrusive memories, or recurring dreams). In most cases, these are unpleasant and affectively charged [1,15,16].

2. Avoidance of activities and situations reminding of the trauma (actual avoidance, a feeling of "numbing" and emotional blunting, detachment, unresponsiveness to the environment, emotional estrangement, anhedonia, restrictive behavior) [1,15,16,33].

3. Excessive physiological arousal (insomnia associated with a flood of unpleasant memories of the traumatic event, hypervigilance – excessive cautiousness, increased startle response) [1,14,15,16,33].

According to ICD-10, symptoms must occur within 6 months after the traumatic event. A latent period may be observed between the action of the stressor and the onset of clinical manifestations [1,2,14,15,16,33].

Patients with PTSD may also exhibit the following disturbances [1,14,15]:

· Psychogenic amnesia, either partial or complete, regarding important aspects of the stressor exposure period.

· Development of depressive experiences, episodic or generalized anxiety.

· Constant internal tension experienced by the victim (due to the exacerbation of the self-preservation instinct) makes affect modulation difficult: sometimes victims cannot suppress bursts of anger even over minor reasons. Acute bursts of fear, panic, or aggression triggered by trauma memories may be noted.

· Sleep disturbances – insomnia (difficulty falling asleep), nightmares. Other phenomena inherent to PTSD and related to sleep include: somnambulism, somniloquy, hypnagogic and hypnopompic hallucinations, and a decrease in stage 4 sleep representation. Sleep-related breathing disorders are also frequently detected in PTSD.

· Subjectively perceived memory impairments: difficulty memorizing; reduced retention of certain information in memory; difficulty with recall. Due to the PTSD patient's fixation on traumatic experiences, memory disorders are not associated with true impairments of various memory functions, but are primarily caused by difficulty concentrating on facts not directly related to the traumatic event and the threat of its recurrence.

· Enhanced superior colliculus reflex ­ to sudden environmental stimuli (light, visual, auditory, tactile), which can easily trigger startling, jumping, screaming, or conversely, "freezing." Sometimes accompanied by autonomic manifestations (increased blood pressure, tachycardia, etc.). Caused by connections of the tectum (human superior colliculi) with the cervical and thoracic segments of the spinal cord.

· Constant avoidance of trauma-related stimuli and numbing — emotional numbness, blocking of emotional reactions, torpor (not observed prior to the trauma) can manifest in the following ways:

1. Efforts to avoid thoughts, feelings, or conversations associated with the trauma.

2. Efforts to avoid activities, places, or people that spark recollections of the trauma.

3. Inability to recall important aspects of the trauma (psychogenic amnesia).

4. Markedly diminished interest or participation in previously significant activities.

5. Feeling of detachment or estrangement from other people.

6. Reduced affect expression (inability to experience love, for example).

7. Feeling of a foreshortened future (e.g., no expectations regarding career, marriage, children, or a long life).

Overall, PTSD causes a clinically significant severe emotional state or impairment in social, occupational, or other important areas of functioning.

In the dynamics of the disorder's development, at the first stage of PTSD, the patient is immersed in a world of trauma-related experiences, with flashbacks being most prominent during this period. At this stage, exacerbation (or first-time diagnosis) of chronic somatic diseases is often noted, especially those involving psychosomatic formation mechanisms (peptic ulcer disease of the duodenum and stomach, cholecystitis, cholangitis, colitis, constipation, bronchial asthma, etc.). Sexological disorders are also noted: decreased libido and erectile function. It is worth noting that specific symptoms manifested in feelings of helplessness, confusion, intrusive frightening images, and persistent ruminations about disease progression can significantly affect coping with somatic disease. Dissociative symptoms caused by psychological trauma prevent timely seeking of help and impair patient compliance [14,16].

Subsequently, memories of the stressful situation become less acute. The patient tries to actively avoid even talking about what happened so as not to "awaken difficult memories." In these cases, irritability, conflict behavior, and even aggressiveness sometimes come to the fore.

The clinical dynamics and long-term prognosis of PTSD can also be influenced by exogenous-organic brain changes, predominantly of traumatic origin, which is most relevant in combatants as a risk group for PTSD development [16,34,35,36,37,38,39]

PTSD Comorbidity

Comorbidity is a hallmark of PTSD. Pathology comorbid with PTSD is widespread and represented by diverse combinations of clinical and psychopathological manifestations. Such conditions have allowed the identification of a group of disorders designated as atypical PTSD, which includes heterogeneous symptom complexes represented by the overlap of PTSD manifestations as a psychogenic disorder with disturbances of other psychopathological registers [16,31,32, 40,41,42,43,44].

Among mental disorders comorbid with PTSD, various researchers cite:

- panic disorder;

- generalized anxiety disorder;

- social phobia;

- specific phobia;

- dissociative disorders;

- major depressive disorder or depressive episode, recurrent depressive disorder;

- bipolar affective disorder;

- psychoactive substance dependence (PAS);

- residual-organic brain disorders;

- organic brain diseases;

- schizophrenia.

· If a patient has a connection between clinical and psychopathological disorders and stress, differentiating PTSD from the following nosologies is recommended for accurate state verification: acute stress reaction (F43.0), adjustment disorder (F43.2), enduring personality change after catastrophic experience (F62.0) [1,2,15];

GCP BLEL 2 Grade of Recommendations B (Level of Evidence 2)

Comments: following the introduction of ICD-11, PTSD will also need to be differentiated from prolonged grief disorder (6B42) [29,30].

Prolonged grief disorder is a disorder characterized by a persistent and pervasive yearning for or longing for the deceased, or a preoccupation with thoughts or memories of the deceased, following the death of someone close to the person. These experiences continue for an abnormally long period of time relative to expected social and cultural norms (e.g., at least 6 months or longer depending on cultural and contextual factors) and are severe enough to cause significant impairment in functioning. These experiences are also characterized by difficulty accepting the death, a sense of loss of part of oneself, anger regarding the loss, guilt, or difficulty engaging in social and other activities.

·      In patients with symptoms of PTSD, differential diagnosis with the following disorders is recommended in order to accurately verify the condition [1,14,15,31,32,33,45,46,47]:

-               stress-related disorders (acute stress reaction, adjustment disorders, enduring personality change after catastrophic experience);

- panic disorder;

- generalized anxiety disorder;

- social phobia;

- specific phobia;

- dissociative disorders;

- residual-organic brain disorders;

- organic brain diseases;

-               specific personality disorders;

-               schizophrenia;

-               acute polymorphic psychotic disorder;

-               hypothalamic disorder;

-               thyroid pathology;

-               pheochromocytoma;

-               psychoactive substance use (e.g., amphetamines, cocaine, etc.);

-               benzodiazepine withdrawal;

-               side effects of pharmacotherapy (e.g., systemic corticosteroids, sex hormones, N06B psychostimulants, agents used for attention deficit hyperactivity disorder, and N06BX other psychostimulants, nootropics, and cardiac medications).

RG CLE 5Recommendation Grade C (Level of Evidence 5).

2. Diagnostics, medical indications and contraindications for diagnostic methods

Comments: ICD-10 defines the following criteria for PTSD:

A. The patient must have been exposed to a stressful event or situation (of either short or long duration) of an exceptionally threatening or catastrophic nature, which is likely to cause pervasive distress in almost anyone.

B. Persistent remembering or "reliving" of the stressor in intrusive flashbacks, vivid memories, or recurring dreams, or in distress when exposed to circumstances resembling or associated with the stressor.

C. The patient must exhibit actual or preferred avoidance of circumstances resembling or associated with the stressor (not present before exposure to the stressor).

D. Either of the following:

1. psychogenic amnesia (F40.0), either partial or complete, regarding important aspects of the period of exposure to the stressor

2. Persistent symptoms of increased psychological sensitivity and arousal (not present before exposure to the stressor), manifested by any two of the following:

a) difficulty falling asleep or staying asleep;

b) irritability or outbursts of anger;

c) difficulty concentrating;

d) hypervigilance;

e) enhanced startle reflex.

E. Criteria B, C, and D occur within six months of the stressful situation or at the end of a period of stress (for some purposes, onset delayed by more than six months may be included, but these cases must be clearly identified separately).

2.1 Complaints and Anamnesis

Algorithm for the diagnosis and management of a patient with PTSD is provided in Appendix B

Main complaints typical of patients with PTSD: intrusive recollections of the traumatic situation, reliving the psychotraumatic event in the form of vivid intrusive memories accompanied by fear or terror, nightmares containing the experienced traumatic event, hypervigilance, desire to avoid any reminders of the psychotraumatic event, thoughts and memories of the event, or avoiding activities, situations, or people reminiscent of the event; anxiety, fear, worry over minor matters, expectation of something terrible happening, a subjective feeling of a persisting threat, inability to feel safe, partial or complete psychogenic amnesia of the stressful event, irritability, outbursts of anger, a sense of unreality, autonomic components of anxiety (hot and cold flashes, sweating, internal trembling, chills, palpitations, muscle tension, etc.), feeling of detachment, emotional numbing, decreased performance, loss of former interests.

•          When interviewing patients who have experienced a psychotraumatic situation, it is recommended to identify impairments characteristic of PTSD (based on the criteria specified in ICD-10) and to assess the presence of a link between psychopathological symptoms and a psychotraumatic situation of a threatening or catastrophic nature in order to verify the diagnosis [1,2,14,15].

RG CLE 5Recommendation Grade C (Level of Evidence 5).

•          When taking a history and conducting a clinical interview in patients who have experienced a psychotraumatic situation, it is recommended to assess the emotional and sensory richness of traumatic memories, to identify the presence of intrusions in the form of recurring and nightmare dreams, flashbacks (persistent memories or "reliving" of the stressor in intrusive recollections, vivid memories, or recurring dreams) in the mental status for the purpose of differential diagnosis from other conditions and planning psychotherapeutic interventions [1,2,14,15].

RG CLE 5Recommendation Grade C (Level of Evidence 5).

•          When taking a history in patients who have experienced a psychotraumatic situation, it is recommended to pay attention to the time elapsed since the psychotraumatic circumstances (symptoms usually develop within six months after the stressful situation) for the purpose of differential diagnosis from other conditions [1,2,14,15].

LeR CLoE 5Level of Recommendation C (Level of Evidence — 5)

Comments: in cases of delayed-onset PTSD, it is important to identify what served as the trigger for the manifestation of symptoms.

•          When interviewing patients with PTSD, it is recommended to use the Structured Clinical Interview for DSM (SCID), Module I "PTSD" (Appendix G3) for the purpose of differential diagnosis with other conditions [1,14,15].

RG CLE 5Recommendation Grade C (Level of Evidence 5).

•          When interviewing patients with suspected PTSD, it is recommended to highlight complaints related to persistent autonomic manifestations of anxiety to be taken into account when selecting therapy [1,14,15].

RG CLE 5Recommendation Grade C (Level of Evidence 5).

•          When taking a history from a patient with PTSD, it is recommended to pay attention to and take into account not only the event that triggered PTSD, but also the burden of traumatic events in general for the purpose of differential diagnosis and planning a psychotherapy strategy [1,14,15].

RG CLE 5Recommendation Grade C (Level of Evidence 5).

Comments: patients who have experienced sexual violence, especially committed by relatives or people close to the patient, require a professional and cautious approach during history taking, as they tend to conceal facts of abuse, particularly when committed by close relatives or acquaintances.

It should also be borne in mind that questioning and recounting the psychotraumatic event can itself act as a factor of secondary traumatization. The patient's condition and its dynamics during the conversation must be assessed with sensitivity. Professional psychiatric and psychotherapeutic experience is of great importance, especially experience in providing care to victims of traumatic stress.

•          When analyzing complaints and taking a history in patients with PTSD, it is recommended to pay attention to the presence of potential comorbid psychiatric disorders (including panic disorder, personality disorders, depressive and bipolar disorders, substance use disorders) for the purpose of differential diagnosis and to account for them when selecting therapy [1,2,14,15].

RG CLE 5Recommendation Grade C (Level of Evidence 5).

•          When analyzing complaints and taking a history in patients with PTSD, it is recommended to take a detailed alcohol history, clarify the experience of psychoactive substance use, and actively identify potential predictors of alcohol or psychoactive substance abuse in order to plan therapy and psychocorrectional interventions [1,14,15].

RG CLE 5Recommendation Grade C (Level of Evidence 5).

• When analyzing complaints and taking a history in patients with PTSD, it is recommended to pay attention to the presence of potential comorbid somatic pathology for the purpose of differential diagnosis and to account for it when selecting therapy [1,14,15].

RG CLE 5Recommendation Grade C (Level of Evidence 5).

• When taking a history and assessing mental status in all patients with PTSD, it is recommended to evaluate suicide risk for the purpose of differential diagnosis of the condition and determining the type and scope of psychiatric care [1,14,15].

LeR CLoE 5Level of Recommendation C (Level of Evidence — 5)

•   When taking anamnesis in patients with PTSD, it is recommended to pay special attention to current stressors in the patient's life, assess available social support, interpersonal problems, current doubts and concerns, as well as identify a history of suicidal behavior in order to assess the severity of the condition and determine the scope of psychiatric, psychotherapeutic, psychological, and social care [1,14,15].

GRC CLEL 5Grade of Recommendation C (Level of Evidence 5)

• When taking the medical history of all patients with PTSD, it is recommended to corroborate the obtained information with objective data from the patient's relatives for greater diagnostic accuracy [1,14,15].

GCR CLeE 5Grade of Recommendation C (Level of Evidence 5)

•    During initial interviews with PTSD patients, it is recommended to assess the specifics of processing the traumatic experience in order to plan further psychotherapeutic interventions [1,14,15].

RG CLE 5Recommendation Grade C (Level of Evidence 5).

Comments: the patient is asked to clarify what was most difficult in the traumatic experience, and the features of existential meta-cognitive processing of the event are determined, for which necessary clarifying questions are asked.

2.2 Physical Examination

• A detailed physical and neurological examination of patients with PTSD symptoms is recommended to rule out somatic pathology, confirm the psychiatric diagnosis, and identify comorbid conditions [1,14,15].

GCR CLEL 5Level of recommendation evidence C (level of data reliability 5).

• For patients with PTSD, the physical examination should begin with an external inspection, measurement of height, body weight, level of physical development, and visual assessment of the integrity of the skin in order to rule out somatic diseases, identify signs of self-harming behavior and injections, and assess somatic status [1,14,15].

RG CLE 5Recommendation Grade C (Level of Evidence 5).

• Patients with PTSD are recommended to have their pulse and blood pressure measured in the supine position (after resting for 5 minutes) and standing (3 minutes after standing up) to assess autonomic manifestations and somatic status [1,14,15].

RG CLE 5Recommendation Grade C (Level of Evidence 5).

• In addition to the standard physical examination, all patients are recommended to undergo an examination of the skin to detect injection marks in order to rule out substance use and identify signs of self-harming behavior [1,14,15].

GCR CLeE 5Grade of Recommendation C (Level of Evidence 5)

2.3 Laboratory Diagnostics

Currently, there are no laboratory diagnostic methods for PTSD. The main purpose of laboratory examinations is to rule out somatic diseases that may present with symptoms similar to PTSD.

• Patients with PTSD are recommended to undergo a complete blood count (CBC), general biochemical blood test, and urinalysis to rule out somatic pathology and assess the risks of developing side effects from psychopharmacotherapy [1,14,15].

RG CLE 5Recommendation Grade C (Level of Evidence 5).

• Patients with PTSD are recommended to undergo a blood test to evaluate thyroid function: assessment of serum total triiodothyronine (T3) levels, serum free triiodothyronine (T3) levels, serum total thyroxine (T4) levels, serum free thyroxine (T4) levels, and blood thyroid-stimulating hormone levels to rule out thyroid pathology [1,14,15,288].

GPR BLEL 2Grade of Recommendation B (Level of Evidence 2).

Comments: Thyroid hormone screening is recommended for first-time patients who have never undergone this test before, or if clinical or anamnestic indications are present.

2.4 Instrumental Diagnostics

Currently, there are no instrumental diagnostic methods for PTSD. The main purpose of instrumental examinations is to rule out somatic (including neurological) diseases that may present with symptoms similar to PTSD.

• Patients with PTSD are recommended to undergo an electrocardiogram (ECG) to assess their somatic status and rule out cardiovascular pathology [1,14,15,289,290,291].

GCR ALeE 3Grade of Recommendation A (Level of Evidence 3).

• Patients with PTSD are recommended to undergo electroencephalography (EEG) to assess brain bioelectrical potentials and rule out paroxysmal states [1,14,15,289,292].

GCR ALeE 3Grade of Recommendation A (Level of Evidence 3).

Comments: electroencephalographic examination is recommended for first-time patients who have not previously undergone these studies, and/or in the presence of clinical or anamnestic indications, as well as when prescribed by a neurologist.

• Patients with PTSD are recommended to undergo duplex scanning of transcranial arteries and veins to rule out vascular pathology [1,14,15,293].

GPR CLoE 4Grade of Recommendation C (Level of Evidence 4).

Comments: duplex scanning of transcranial arteries and veins is recommended for first-time patients who have not previously undergone these studies, and/or in the presence of clinical or anamnestic indications, as well as when prescribed by a neurologist

• Patients with PTSD are recommended to undergo brain magnetic resonance imaging (MRI) to rule out organic brain lesions [1,14,15,289,294].

GGR BLEL 3Grade of Recommendation B (Level of Evidence 3).

Comments: Brain MRI is recommended for first-time patients who have not previously undergone these studies, and/or in the presence of clinical or anamnestic indications, as well as when prescribed by a neurologist

2.5 Other Procedures

Clinical and psychological psychodiagnostic examination

PTSD is a disorder in whose pathogenesis and clinical (clinico-psychopathological) manifestations psychological factors play a major role, and psychotherapy is one of the effective treatment methods. Based on the biopsychosocial concept of mental disorders, it is important to involve medical psychologists in multidisciplinary teams to participate in diagnostic and treatment measures in order to determine the preserved and impaired individual psychological characteristics of the patient caused by the illness, identify targets for psychotherapeutic intervention, and objectify the dynamics of therapeutic measures.

One of the important competencies of a medical psychologist in providing medical care to patients with PTSD is psychological assessment. Various scales that have undergone adaptation and validation can be used depending on the goals of the study. The methods suggested below are used optionally, and the list of possible methods for conducting an experimental psychological examination is not limited to them.

• Patients with PTSD are recommended to use psychometric scales and symptom questionnaires for PTSD screening, assessment of condition severity, symptom severity, and their dynamics during therapy [16,47,48,49,50]:

1. Trauma Screening Questionnaire (TSQ, Brewin C. et al., 2002) (Appendix G1) [47].

2. Clinician-Administered PTSD Scale for DSM-5 (CAPS) (Appendix G2) [48,295].

3. Structured Clinical Interview for DSM (SCID), Module I "PTSD" (Appendix G3) [16,296].

4. Impact of Event Scale-Revised (IES-R) (Appendix G4) [48,49].

5. Mississippi Scale for Combat-Related Posttraumatic Stress Disorder (civilian and military versions) (Appendix G5) [48]

6. Combat Exposure Scale (CES) (Appendix G6) [16,297,298].

7. Psychophysiological Stress Reaction Severity Scale (Appendix G7) [16].

8. Peritraumatic Dissociative Experiences Questionnaire (Appendix G8) [48].

9. Dissociative Experiences Scale (DES) (Appendix G9) [49].

10. Beck Hopelessness Scale (BHS) (Appendix G10) [49].

11. Treatment Outcome PTSD Scale (TOP-8) (Appendix G11) [49,50].

RG CLE 5Recommendation Grade C (Level of Evidence 5).

Comments: the presented methods are psychometric and/or symptomatic questionnaires that allow for an objective assessment of the nature and severity of clinical symptoms, their dynamics, and the effect of ongoing treatment. A more comprehensive clinical-psychological and experimental-psychological evaluation can be performed by a medical psychologist depending on specific diagnostic tasks or to determine the targets of psychotherapeutic intervention. The choice of psychological diagnostic methods and techniques falls within the competence of the medical psychologist, provided that the data requested by the attending physician are presented in the text of the psychological report. Various scales that have undergone adaptation and validation may be used depending on the goals of the study. These methods can be used optionally, and the list of possible methods for conducting an experimental-psychological examination is not limited. At the same time, one of the most important components of a medical psychologist's participation in providing medical care to patients with PTSD is psychological diagnostics. All main types, methods, and techniques accepted both in psychological diagnostics in general and in its applied clinical section, referred to as "medical psychodiagnostics" or "clinical psychological diagnostics," are used. In accordance with the basic theoretical tenets of psychological diagnostics, clinical practice utilizes both clinical-psychological (expert) methods (clinical conversation, observation, interview, analysis of activity products, etc.) and experimental-psychological methods. Questionnaire methods rely heavily on the self-evaluative nature of the data obtained and have certain limitations regarding the objectivity of such data. On the other hand, they reflect to a greater extent the individual psychological characteristics of the personality itself and its preservation/alteration in the situation of illness, and also reveal a wide range of connections, attitudes, coping and response styles, and other clinically significant characteristics of the personality and personal-environmental interaction inherent in the subject. Such data should be evaluated within the framework of a personalized approach in implementing the biopsychosocial paradigm of modern anthropocentric and clinical sciences. At the same time, clinical methods are organically woven into the procedures of experimental-psychological research and are used directly during the execution of tasks and test methods by the subject. A distinguishing feature of using clinical- and experimental-psychological methods in solving psychological diagnostic tasks is the accounting and analysis of specifics caused by the patient's mental and psychological status altered by the disease.

3. Treatment, including drug and non-drug therapies, diet therapy, and pain management

PTSD is a disorder that has high comorbidity with a large number of mental and somatic disorders. In the treatment of patients with PTSD and comorbid disorders, it is also advisable to rely on clinical guidelines and care standards for these conditions.

3.1 Complex therapy

• Patients with PTSD are recommended a combination of psychopharmacotherapy and psychotherapy as the main therapeutic strategy to increase treatment effectiveness [51,52].

RG CLE 5Recommendation Grade C (Level of Evidence 5).

Comments: data from modern scientific studies confirm the efficacy of both psychopharmacotherapy and psychotherapy (cognitive-behavioral, narrative exposure therapy, etc.) in the treatment of PTSD [52]. There are isolated studies showing high efficacy of the combined use of psychopharmacotherapy and psychotherapy, however, in a number of published meta-analyses, the conclusions are contradictory, and the urgent need for further research in this area is actively emphasized [53]. In the management of patients with PTSD, priority remains with combination therapy, although psychopharmacotherapy and psychotherapy can be used separately depending on the conditions. Psychotropic drugs (N06A antidepressants, N05B anxiolytics, N05C hypnotics and sedatives, N05A antipsychotics) are widely used in the treatment of PTSD, since trauma-focused psychotherapy may be unavailable (especially at the onset of the disease) or poorly tolerated. The choice of therapy strategy and the ratio of psychopharmacotherapy and psychotherapy depend on the patient's preference for a particular treatment method, clinical symptom manifestations, treatment stage, personality traits, current resources, and organizational capabilities, and should be flexibly assessed taking into account a personalized approach in each specific case. There are indications and contraindications for both psychopharmacological and psychotherapeutic treatment. These are primarily related to the patient's condition, side effects, and organizational conditions [54,55].

3.2. Psychopharmacotherapy

First-line therapy

Drugs used in PTSD and their dosages are listed in Appendix A3. "Reference materials, including compliance of indications and contraindications, routes of administration and doses of medicinal products, instructions for use of the medicinal product" in the table "Recommended doses of drugs for the treatment of PTSD"

• For patients with PTSD, as first-line drugs, it is predominantly recommended to initiate therapy with selective serotonin reuptake inhibitors (SSRIs) (paroxetine** 20–50 mg/day, sertraline** 25–200 mg/day, #fluoxetine** 20–40 mg/day) or #venlafaxine 75–225 mg/day to reduce the intensity of intrusions, decrease sensitivity to external and internal stimuli triggering the re-experience of traumatic events, reduce the severity of affective disorders, and stabilize mood. The recommended duration of therapy is 6–12 months, most often about a year after stabilization of the condition [51,53,302].

GCR ALEL 1Grade of Recommendation A (Level of Evidence 1).

Comments: after establishing a diagnosis of PTSD, patients are recommended as a first-line course for the first 4–6 weeks to either undergo monotherapy with SSRIs or #venlafaxine. The efficacy of therapy is evaluated 4–6 weeks after initiation. If efficacy is sufficient, treatment is continued for the full course (6–12 months after stabilization). In case of insufficient efficacy, it is advisable to increase the drug dose to the maximum therapeutic level or switch to another first-line SSRI or #venlafaxine. The treatment option should be chosen individually for each patient, taking into account the psychotropic and somatotropic effects of the drug, potential adverse events, the patient's mental and somatic status, clinical characteristics of the disease, and comorbid disorders.

Antidepressant monotherapy is started at minimal dosages and gradually titrated to therapeutic ones. The anxiolytic effect develops individually within 2–8 weeks. Therefore, and taking into account possible clinical deterioration at the start of SSRI administration, at the first stage of treatment it is advisable to use a combination with benzodiazepine derivatives, especially with pronounced anxiety and autonomic disorders. Careful attention should be paid to contraindications for benzodiazepine derivatives, including avoiding the prescription of this group of drugs to patients with a high risk of developing dependence.

The advantages of the recommended antidepressants include a favorable efficacy-tolerability-safety profile, the possibility of once-daily administration, and the presence of a long-term therapeutic effect; the disadvantages include delayed onset of effect, possible anxiogenic effect in the first week of therapy, the need for dosage titration, negative impact on sexual function, development of nausea, and certain other side effects.

• For patients with PTSD presenting with marked anxiety, fear, irritability, agitation, and autonomic disorders at the first stage of therapy, short-term use of drugs from the benzodiazepine derivative group is recommended for the relief of anxiety, symptoms from the physiological arousal cluster, autonomic symptoms, and psychomotor agitation:

– diazepam** 5–15 mg/day (for psychomotor agitation associated with anxiety, comorbid acute anxiety-phobic, and anxiety-depressive states). The dose is usually divided into 2–3 doses. The duration of a diazepam** course should not exceed 4 weeks; in severe cases, up to 8–12 weeks is permitted, including the tapering period [57,303,304,307,308].

RG CLE 5Recommendation Grade C (Level of Evidence 5).

– lorazepam** 2–10 mg/day (for anxiety, irritability, sleep disturbances, autonomic disorders). It is usually prescribed at 2–3 mg/day, divided into 1–3 doses, and then, if necessary, the daily dose is increased to a maintenance dose, which most often ranges from 2 mg to 6 mg per day, divided into 1–3 doses. To relieve symptoms, it is recommended to use the lowest effective doses possible. The dose of lorazepam** must be increased gradually, starting with an increase in the evening dose. A maximum of up to 10 mg per day can be prescribed. For sleep disturbances caused by anxiety, 2 to 5 mg of lorazepam** is usually prescribed once daily before bedtime [57,303,309].

GCR CLOCE 4Grade of Recommendation C (Level of Evidence 4)

– clonazepam** 1–4 mg/day (for severe/paroxysmal fear, psychomotor agitation against the background of reactive psychoses). To relieve symptoms, it is recommended to use the lowest effective doses possible. The dose is usually divided into 2–3 doses. If necessary, the dose is increased gradually, every 3 days, by no more than 0.25–0.5 mg, until the corresponding therapeutic effect or maximum daily dose is reached [57,303].

GGR BLEL 3Grade of Recommendation B (Level of Evidence 3).

– alprazolam 0.25–4.5 mg/day (for anxiety disorders, comorbid panic disorder, or depressive disorder, the dose may reach up to 6–10 mg/day). Administration is started with minimal doses (0.25–0.5 mg/day) followed by an increase first in the evening hours, then in the daytime hours over several days or weeks. For anxiety states, the initial daily dose is 0.75–1.5 mg and can be increased to 3–4.5 mg/day. A course of treatment with alprazolam is permissible for up to 3 months; discontinuation of therapy should be carried out over 2–6 weeks, reducing the daily dosage by no more than 500 mcg every 3 days; slower withdrawal is permitted [57,303].

Level of Recommendations B (Level of Evidence 2)Level of Evidence 2Level of Recommendations B (Level of Evidence 2).

Comments: a number of specialists adhere to the view that benzodiazepine derivatives are effective in the short term, reducing anxiety, irritability, and symptoms of autonomic arousal, but with prolonged use they may exacerbate avoidance symptoms and social maladaptation. Negative impact on cognitive functioning can reduce the effectiveness of psychotherapy. Prolonged use of benzodiazepines is justified in the absence of response to other treatments or their intolerance. Most benzodiazepine derivatives were approved for the therapy of so-called anxiety states even before PTSD appeared as an independent nosology; studies of their efficacy in RCTs for the treatment of PTSD are virtually nonexistent.

The advantages of benzodiazepine derivatives are a rapid onset of effect; anxiolytic and vegetotropic effects develop within 30–60 minutes after oral or injection administration, and in patients with suicidal tendencies, they allow rapid control over symptoms. They are characterized by good tolerability and a wide therapeutic window—safety in case of overdose. Given that the effect of antidepressants is achieved after 4–6 weeks of therapy, short-term prescription of benzodiazepine derivatives at the first stage helps reduce the intensity of anxiety symptoms.

Before prescribing this group of drugs, a thorough addiction history should be taken. It is not advisable to prescribe them to patients with a history of substance abuse or at risk of developing substance dependence. Attention should be paid to patient compliance, as some patients are prone to exceeding recommended dosages. Benzodiazepine derivatives (N05BA) can cause dependence and are associated with withdrawal symptoms upon abrupt cessation of therapy. Therefore, the duration of their use should be limited to 3 weeks. The duration of use is also limited by significant adverse effects—sedation, dizziness, impaired coordination, reduced concentration and memory, impaired psychomotor functions, the risk of dependence and drug tolerance, and pronounced withdrawal symptoms manifesting as clinical deterioration and increased anxiety after discontinuation; hence, treatment must be restricted to short courses (no more than 3 weeks) [58].

There are no evidence-based studies on the efficacy of bromdihydrochlorphenylbenzodiazepine**. However, in Russian medical practice, it has traditionally been used to treat anxiety disorders, manage panic attacks, and treat veterans with PTSD. When prescribing benzodiazepine derivatives, the half-life should be taken into account when deciding on the dosing frequency and preventing accumulation effects (due to its long half-life, bromdihydrochlorphenylbenzodiazepine** is not recommended to be prescribed more than 1–2 times a day; alprazolam, due to its relatively short half-life, should be prescribed at a frequency of at least 3 times a day).

• Patients with PTSD whose clinical presentation includes disorders accompanied by emotional tension, anxiety, autonomic disorders, apathy, fatigue, and depressed mood are recommended to receive tofisopam to relieve these manifestations (50–300 mg/day) [59,60,61,62,63,64,65,66].

GGR BLEL 3Grade of Recommendation B (Level of Evidence 3).

Comments: tofisopam, a benzodiazepine derivative, has a different location of the nitrogen group, which determines a number of its specific characteristics: it does not cause physical dependence, lacks sedative and myorelaxant effects, does not impair cognitive functioning (hence classified as a daytime tranquilizer), does not potentiate the effects of alcohol, and is used in the complex therapy of alcohol withdrawal syndrome. Due to its pronounced vegetostabilizing effect, it is widely used in neurology to treat psychovegetative syndrome, which shares common symptoms with the third symptom cluster of PTSD. An open-label study in a small sample demonstrated the efficacy of tofisopam in the treatment of PTSD. Adults are prescribed 50–100 mg (1–2 tablets) 1–3 times a day. In case of paroxysmal deterioration, a single dose of 1–2 tablets can be taken. The maximum daily dose is 300 mg, and the duration of therapy is 4–12 weeks. The drug can be used in combination therapy with other agents.

• Patients with PTSD whose clinical presentation includes disorders accompanied by anxiety, emotional tension, autonomic disorders, somatoform disorders, mild psychomotor agitation, restlessness, and sleep disturbances are recommended to receive alimemazine (15–80 mg/day) to relieve these manifestations [67,68].

RG CLE 5Recommendation Grade C (Level of Evidence 5).

Comments: course treatment should be initiated with 2.5–5 mg in the evening, with a gradual increase in the daily dose until the desired effect is achieved. The daily dose can be divided into 3–4 administrations. The duration of course treatment can range from 2 to 6 months or more and is determined by the physician depending on the patient's condition in accordance with the package leaflet. If necessary, it can be used episodically (20–30 minutes before bedtime) to achieve a sedative or hypnotic effect. Adverse effects are extremely rare and mild. The drug may be used in combination therapy with other agents.

• Patients with PTSD are recommended to receive etifoxine (150–200 mg/day) as an anxiolytic alternative to benzodiazepine derivatives to eliminate anxiety, fear, inner tension, irritability, as well as signs of heightened alertness and autonomic arousal [69,70,71,72,72,74].

GGR ALOC 2Grade of recommendation A (Level of evidence 2).

Comments: etifoxine has proven itself well in the treatment of stress-related disorders with anxiety syndrome. Its anxiolytic effect, lack of addictive potential, and absence of side effects typical of benzodiazepines are due to highly specific modulation of GABA receptor activity resulting from allosteric interaction with them, as well as activation of the translocator protein (known as the peripheral benzodiazepine receptor), which leads to an intensification of neurosteroid biosynthesis, thereby exerting its anxiolytic, analgesic, and neurotrophic effects. Adverse effects of etifoxine include drowsiness, allergic skin reactions, acute hypersensitivity reactions, hepatitis, and uterine bleeding. Etifoxine is used at a dose of 150–200 mg/day. The duration of treatment ranges from several days to 4–6 weeks, depending on the patient's condition. The drug can be used in combination therapy with other agents.

• Patients with PTSD are recommended to use non-benzodiazepine anxiolytics—#hydroxyzine** (25–100 mg/day)—in the presence of comorbid anxiety disorders to reduce anxiety levels [75,76,77,78].

GCR ALEL 1Grade of Recommendation A (Level of Evidence 1).

Comments: hydroxyzine** is prescribed to reduce anxiety levels (symptomatic treatment of anxiety). It does not depress the cerebral cortex, but its action may be related to the suppression of activity in certain key zones of the subcortical region of the central nervous system. When oral dosage forms are used, the sedative effect occurs within 30–45 minutes. Hydroxyzine** also exhibits spasmolytic and sympatholytic actions and demonstrates moderate analgesic activity. The recommended dosage is 25–100 mg/day. Since responses to hydroxyzine** vary, it is recommended to start treatment with low doses and gradually increase to the optimal dose, adjusting it according to the patient's therapeutic response. If anxiety manifests as insomnia, the main dose is taken in the evening before bedtime. The duration is determined individually, usually lasting 4–8 weeks. The drug can be used in combination therapy with other agents.

• Patients with PTSD are recommended to use non-benzodiazepine anxiolytics—buspirone (20–30 mg/day)—in the presence of comorbid anxiety disorders to reduce anxiety levels [75, 78].

GGR CLOC 2Grade of recommendation C (Level of evidence 2).

Comments: unlike benzodiazepine derivatives, buspirone does not possess muscle relaxant or anticonvulsant properties. Its sedative effect is significantly weaker than that of typical anxiolytics and does not impair psychomotor functions. In terms of anxiolytic activity, buspirone is roughly similar to benzodiazepine derivatives. Buspirone does not cause tolerance or dependence, and withdrawal symptoms do not develop after completing a course of treatment. The effect of buspirone develops gradually. The therapeutic effect begins to appear between the 7th and 14th days of therapy, and the maximum effect is achieved approximately 4 weeks after the start of treatment. Therefore, this drug is not prescribed episodically. The recommended starting dose is 15 mg, which can be increased by 5 mg per day every 2–3 days. The usual daily dose is 20–30 mg per day. The maximum single dose is 30 mg, and the maximum daily dose should not exceed 60 mg. The drug can be used in combination therapy with other agents.

Second-line therapy

• As second-line drugs, the use of non-selective monoamine reuptake inhibitors—#amitriptyline** 75–150 mg/day orally, #imipramine** 75–250 mg/day, and #mirtazapine (30–60 mg/day)—is recommended for symptom management [81,82,83,84,85,86,299].

Level of Recommendations B (Level of Evidence 2)Level of Evidence 2Level of Recommendations B (Level of Evidence 2).

Comments: one should take into account the risk of overdose associated with #amitriptyline** and #imipramine**, their more pronounced side effects, and lower patient adherence to therapy with these drugs. It is not recommended to prescribe these drugs to patients at high suicide risk without constant supervision. Several studies have demonstrated the efficacy of the antidepressant #mirtazapine. The duration of therapy is also 6–12 months.

Third-line therapy

• In patients with PTSD when antidepressant therapy or its combination with benzodiazepine derivatives is ineffective, third-line drugs are recommended for symptom management [51,53].

Level of Recommendations B (Level of Evidence 2)Level of Evidence 2Level of Recommendations B (Level of Evidence 2).

• Patients with PTSD may be prescribed the antiepileptic drug #lamotrigine at a dose of 25–500 mg/day or #topiramate** (200–400 mg/day) as an alternative in the absence of a response to previous courses of therapy in order to increase treatment efficacy [53,87,88,89,90,91].

GCR ALEL 1Grade of Recommendation A (Level of Evidence 1).

Comments: The dose of #lamotrigine should be titrated weekly, especially if the clinical presentation of PTSD features pronounced mood swings, difficulties in affective regulation, or comorbid mature personality disorder. Frequent skin rashes, up to toxic epidermal necrolysis, should be kept in mind as common side effects. #Lamotrigine can be prescribed as an adjunct to the main course of therapy.

Therapy with #topiramate** is recommended to be initiated at a low dose followed by a gradual titration to an effective dose. Dose titration starts at 25–50 mg taken at bedtime for 1 week. Subsequently, at weekly or biweekly intervals, the dose can be increased by 25–50 mg and taken in two divided doses. Dose titration should be guided by the clinical effect. In some patients, the effect may be achieved with once-daily administration. To achieve the optimal treatment effect with #topiramate**, monitoring its plasma concentration is not necessary.

• In patients with PTSD, if previous courses of therapy are ineffective or if there are symptoms such as intrusive thoughts about the traumatic event, flashbacks, explosiveness, aggressive behavior, sleep disturbances, as well as dissociative symptoms, disorganized behavior, and comorbid psychotic disorders, the prescription of antipsychotics in accordance with indications is recommended [92,93,94,95,96].

Level of Recommendations B (Level of Evidence 2)Level of Evidence 2Level of Recommendations B (Level of Evidence 2).

Comments: this group of drugs can be used to treat symptoms such as intrusive thoughts about the traumatic event, flashbacks, explosiveness, aggressive behavior, and sleep disturbances, as well as in cases where the clinical presentation features prominent dissociative symptoms and disorganized behavior, or comorbid psychotic disorders. The prescription of antipsychotics in low doses can be used as adjunctive therapy to the standard treatment regimen. They are the drugs of choice in the presence of psychotic symptoms, auditory, visual, and tactile hallucinations, delusional disorders, aggressive ideas, feelings, and behavior. They can also be useful as behavioral correctors when anger, explosiveness, and aggressive behavior take precedence over anxiety. Studies on the efficacy of antipsychotics in the treatment of PTSD vary widely in design, ranging from case reports to open-label studies and RCTs. The drugs can be used in combination therapy with other agents.

• Patients with PTSD with indications for antipsychotic therapy are recommended to be prescribed #risperidone** (0.5–8 mg/day) orally to correct symptoms [100,101,102].

RG CLE 5Recommendation Grade C (Level of Evidence 5).

Comments: The antipsychotic agent #risperidone** may be used as third-line drugs due to a large number of side effects, such as akathisia or extrapyramidal symptoms, and metabolic syndrome, despite the fact that lower doses are used for the treatment of PTSD. It can also be prescribed as an adjunctive therapy to the standard treatment regimen.

• Patients with PTSD with indications for antipsychotic therapy are recommended to be prescribed #quetiapine** (50–300 mg/day) to correct symptoms [97,98,99].

GCR CLOE 4Grade of Recommendation C (Level of Evidence 4).

Comments: The antipsychotic agent #quetiapine** may be used as third-line drugs due to a large number of side effects, such as akathisia or extrapyramidal symptoms, and metabolic syndrome, despite the fact that lower doses are used for the treatment of PTSD. It can also be prescribed as an adjunctive therapy to the standard treatment regimen.

• Patients with treatment-resistant PTSD are recommended to be prescribed #olanzapine** at a dose of 5–20 mg/day together with SSRI antidepressants or as monotherapy in order to overcome resistance [103,104,105,106].

Level of Recommendations B (Level of Evidence 2)Level of Evidence 2Level of Recommendations B (Level of Evidence 2).

Comments: currently, there is no universal definition of treatment-resistant PTSD; in most studies, non-responders are considered to be patients who have less than 70% improvement on the CAPS scale and have received treatment with one or two different SSRIs at the maximum tolerated dose for 8–12 weeks. In such cases, it is recommended to use #olanzapine** at a dose of 5–20 mg/day together with SSRI antidepressants or as monotherapy.

• Patients with PTSD presenting with explosiveness and behavioral disorders in the clinical picture are recommended to be prescribed tiapride (200–300 mg/day), #chlorprothixene (15–100 mg/day), or alimemazine (15–80 mg/day) for behavioral correction [67,68,107,108,109,110,111,112,300,301,310].

RG CLE 5Recommendation Grade C (Level of Evidence 5).

Comments: there are no evidence-based studies regarding tiapride, alimemazine, and #chlorprothixene. However, in Russian medical practice, these drugs are traditionally used to treat explosiveness and behavioral disorders as agents possessing anti-aggressive (antidysphoric) activity. The drugs can be prescribed as an adjunct to the standard treatment regimen.

• Patients with PTSD are recommended to continue therapy for about a year after the onset of a therapeutic effect from the administered therapy in order to stabilize the effect and prevent relapse. The combination of drugs and dosages at various stages of treatment are determined individually depending on the patient's condition and the dynamics of therapy; appropriate psychometric tools can be additionally used to assess the condition dynamically [51].

RG CLE 5Recommendation Grade C (Level of Evidence 5).

• If there is an insufficient effect from psychopharmacotherapy, it is recommended to verify that the drug was used at the maximum therapeutic dose and that the patient was compliant in order to confirm the fact of an inadequate therapeutic response to a specific drug [113,114].

GCR CLOE 4Grade of Recommendation C (Level of Evidence 4).

Comments: in case of ineffectiveness of the first course of therapy, it is first necessary to ensure patient compliance, since non-adherence to the drug regimen is the cause of treatment resistance in a significant number of cases. Treatment non-adherence may be associated with side effects, poor patient engagement in therapy, low motivation, or the perception of a lack of treatment effect (especially typical when taking antidepressants, the effect of which is delayed). To improve compliance, a psychoeducational discussion should be held with the patient, discussing potential side effects, the need for regular medication intake, and the gradual development of the therapeutic effect of antidepressants. Keeping a medication log or using a smartphone app with reminders plays a positive role.

• In patients with PTSD receiving psychotropic medications (N06A antidepressants, N05B anxiolytics, N05C hypnotics and sedatives, N05A antipsychotics), it is recommended to evaluate the following potential side effects of psychopharmacotherapy: sedation, drowsiness, lethargy, urinary retention, constipation or diarrhea, nausea, headaches, dizziness, coordination impairment, concentration impairment, memory impairment, development of dependence and drug tolerance, etc., within a personalized approach to reduce the likelihood of side effects and complications from the ongoing therapy [51].

RG CLE 5Recommendation Grade C (Level of Evidence 5).

Comments: at the same time, adequate dosages and prescribing medications strictly according to indications significantly reduce the risk of side effects.

When using non-selective monoamine reuptake inhibitors, regular monitoring of blood pressure and ECG is also necessary; when using antipsychotics, monitoring for signs of metabolic syndrome, primarily weight, is required.

• Patients with PTSD receiving psychopharmacological medications are recommended to have an evaluation of treatment efficacy and tolerability performed on days 7, 14, and 28 of psychopharmacotherapy and subsequently once every 4 weeks until the end of the treatment course in order to adjust the ongoing treatment in a timely manner [51].

RG CLE 5Recommendation Grade C (Level of Evidence 5).

Comments: in cases of insufficient efficacy of monotherapy after 4–6 weeks, changing the drug or using combination treatment regimens is recommended. In case of intolerance or insufficient efficacy, dosage adjustments or a drug change are performed [51]. A significant contribution to the overall therapeutic efficacy in clinical practice is also made by the physician's qualification, who through experience can anticipate which of the drugs will "suit" a given patient better or which patient will respond better to this treatment. This reflects the obvious advantages of personalized drug selection to achieve the best outcomes of the therapeutic process, although evidence regarding the guidelines that can be used for a differentiated approach to therapy—and which most likely underlie the intuition of an experienced physician—is extremely scarce. Since RCTs conducted to evaluate the efficacy of drugs in the treatment of PTSD did not account for the specific features of clinical manifestations (the predominance of certain symptom complexes, the management of behavioral disorders in cases of dominant anger affect, or the dominance of avoidance and social isolation in the clinical picture), there are certain difficulties in applying their results when implementing a personalized approach in medicine.

3.3. Psychotherapy

The study of the efficacy of psychotherapy in the treatment of PTSD began almost immediately after it was classified as an independent nosology; therefore, among more than 300 RCTs conducted, more than half of the protocols studied one or another method of psychotherapy. To date, there is a large body of evidence supporting the efficacy of psychotherapy for this pathology [115,116,117,118]. One of the latest umbrella meta-analyses evaluating the efficacy of treatment for mental disorders showed that for PTSD (unlike other mental disorders), there was a medium effect size for cognitive behavioral therapy (CBT) of PTSD compared to standard care, as well as a medium effect size for pharmacotherapy of PTSD using venlafaxine and SSRIs. Regarding the duration of sustained effect, psychotherapy proved to be more effective than pharmacotherapy [119]. The large number of sources demonstrating the efficacy of CBT is likely related to the ability within scientific research to reproduce specific techniques, rather than an absolute priority of this method for patients with post-traumatic stress disorder. Other psychotherapeutic methods with a smaller evidence base today may be just as effective, and perhaps in certain cases more effective, than CBT [120,121]. However, it must be remembered that the design of evidence-based studies in psychotherapy is quite complex, and clinical practice differs from a scientific experiment in many parameters. When choosing a particular method in practice, one should take into account the specifics of trauma in a PTSD patient, clinical and individual-psychological characteristics, patient motivation, and the availability of a particular psychotherapeutic method [122].

Contraindications to psychotherapeutic treatment [1]:

1) patients with a fear of self-disclosure and a predominance of denial among their psychological defense mechanisms;

2) patients with insufficient motivation for change and obvious secondary gain from the illness;

3) patients with low interpersonal sensitivity;

4) patients who are unable to regularly attend psychotherapy sessions;

5) patients who will not participate in the process of active verbalization and listening in individual and group psychotherapy;

6) patients whose characterological features do not allow them to work constructively in individual and group psychotherapy and benefit from this work (who constantly act out their emotions outwardly as a defense mechanism rather than observing their psychological state; or patients with severe negativism or rigidity);

7) patients in a state of alcohol or drug intoxication;

8) patients in an acute psychotic state.

• It is recommended that patients with PTSD use various types of psychotherapy in combination with psychopharmacotherapy or as a standalone treatment to rapidly overcome the consequences of psychological trauma, reduce anxiety and tension, and correct thinking and emotional state [15,116,117,118].

GPP ALOE 1Grade of Recommendation A (Level of Evidence – 1).

• It is recommended that patients with PTSD receive trauma-focused cognitive behavioral therapy (TF-CBT)—including its specific variants such as cognitive therapy, cognitive processing therapy, cognitive therapy, CBT with prolonged exposure, narrative exposure therapy—as well as eye movement desensitization and reprocessing (EMDR) as methods with the highest evidence base for evaluating efficacy [123,124,125,126,127,129].

GPP ALOE 1Grade of Recommendation A (Level of Evidence – 1).

• It is recommended to conduct psychoeducation for patients with PTSD regarding the causes, characteristic symptoms, dynamics, treatment, and prognosis of the disease in order to reduce anxiety, improve compliance, and increase motivation for psychotherapeutic treatment [1]

Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).

• Patients with PTSD are recommended to undergo cognitive psychotherapy lasting 15–20 sessions, conducted weekly individually and/or in a group, to modify pessimistic and catastrophic appraisals and memories related to the psychotrauma, with the aim of overcoming behavioral and cognitive patterns that maintain avoidance and hinder normal daily functioning [130,131].

GCR ALOE 2Grade of Recommendation A (Level of Evidence – 2).

Comments: the main objective of therapy is to modify pessimistic and catastrophic appraisals and memories related to the psychotrauma in order to overcome behavioral and cognitive patterns that maintain avoidance and interfere with normal daily functioning. Under the guidance of a psychotherapist, the patient learns to identify internal and external stimuli, as well as specific triggers maintaining PTSD symptoms. To reduce the severity of intrusions, a thorough assessment of memories and integration of the traumatic experience are performed. The Socratic dialogue is recommended for addressing dysfunctional thoughts related to trauma appraisal and core beliefs that maintain a sense of constant threat. Additional targets include dysfunctional cognitive and behavioral patterns that block adaptive coping strategies and the recovery of coherent memories of the traumatic event, such as rumination, safety-seeking behaviors, and thought suppression.

• Patients with PTSD are recommended to undergo cognitive processing therapy (12 sessions) to overcome avoidance associated with traumatic experience, re-conceptualize it, and learn problem-solving skills [132,133,134].

GCR ALOE 2Grade of Recommendation A (Level of Evidence 2).

Comments: the method has demonstrated efficacy in reducing PTSD symptoms across various types of traumatic exposures, including natural disasters, child abuse, combat exposure, and rape; the standard protocol comprises 12 sessions.

The main goal is to overcome avoidance associated with the traumatic experience, re-conceptualize it, and learn problem-solving skills. This is achieved through psychoeducation, keeping an automatic thought record, identifying maladaptive thoughts that maintain PTSD symptoms, and utilizing Socratic dialogue aimed at changing attitudes toward the traumatic experience, such as overcoming self-blame. At the final stage, skills for evaluating and adjusting beliefs associated with the traumatic event are refined, and adaptive cognitive strategies regarding safety, trust, power, control, esteem, and intimacy—areas that may have been affected by the traumatic experience—are consolidated, with the primary objective of improving the patient's daily functioning and quality of life.

• Patients with PTSD are recommended to undergo biofeedback therapy (10 sessions) to reduce anxiety and tension, learn self-regulation skills, and lower tension levels [135,136,137,138,139].

GCR BLOE 2Grade of Recommendation B (Level of Evidence 2).

• Patients with PTSD are recommended to undergo individual cognitive behavioral psychotherapy with prolonged exposure (15–20 sessions) to increase tolerance to unpleasant stimuli associated with the traumatic experience, and to help patients gradually confront feelings, memories, and situations related to the trauma [140,141,142,143,144,145,146,147,148].

GCR ALOE 1Grade of Recommendation A (Level of Evidence 1).

Comments: the main goal of this method is to increase tolerance to aversive stimuli associated with traumatic experiences; it aims to teach patients to gradually confront feelings, memories, and situations related to the trauma. The primary objective is to teach that triggers and memories are safe and tolerable and should not be avoided. The duration of therapy is about 3 months with weekly sessions lasting 60 to 120 minutes, with a total of 8 to 15 sessions, and in some cases, 15 to 20 are recommended. At the beginning of therapy, the psychotherapist outlines the treatment plan and validates the patient's traumatic experience, followed by training in anxiety coping skills and breathing exercises. After this, the exposure itself is conducted; for its successful implementation, a therapeutic alliance and an atmosphere of safety must be established, where confrontation with highly frightening stimuli is possible under conditions of emotional support. Exposure can be conducted in imagination or as an in vivo homework assignment; currently, virtual reality (VR) programs are actively used for exposure. When conducting VR exposure, the session duration is 45–60 minutes, and each scene is repeated until the level of distress decreases by half compared to the first presentation. The next scene is used after the patient confirms their readiness; the goal of therapy is to make discomfort tolerable. The pace of psychotherapy is determined by the patient's condition and individual characteristics [147,148].

• Patients with PTSD are recommended to undergo individual narrative exposure therapy lasting from 4 to 10 sessions to process traumatic experiences [149,150,151,152,153].

GCR ALOE 2Grade of Recommendation A (Level of Evidence 2).

Comments: the method is widely used to help refugees; the main task is to construct a sequential life narrative into which the traumatic experience is integrated. Important aspects of the psychotherapist's behavior include empathetic understanding, active listening, unconditional positive regard, and maintaining the therapeutic alliance. Under the guidance of the psychotherapist, the patient creates their life narrative in chronological order, focusing mainly on the traumatic experience but also including positive events. This is believed to integrate the context of cognitive, affective, and sensory memories of the trauma. By creating the narrative, the patient forms a coherent and consistent biographical story out of fragmentary memories. An important goal of psychotherapy is to integrate into the narrative the past with episodes of traumatization, the present with traumatic memories of past events, and the future, where the traumatic experience is defined as one of life's episodes.

• Patients with PTSD are recommended to receive individual dialectical behavior therapy (DBT), especially in cases of prolonged or multiple traumatization, with the number of sessions ranging from 40 to 50, aiming to develop an alternative evaluation of the traumatic experience [154].

Level of Recommendation ALevel of Evidence 2Level of Recommendation A (Level of Evidence 2).

Comments: the very name defines the main goal of therapy—the formation of an alternative evaluation of the traumatic experience, which is often perceived by patients unconditionally as unbearable and hopeless; the behavioral module is aimed at developing optimal behavioral patterns in the process of comparing different, sometimes contradictory options. The psychotherapist's task in each individual case is to find the optimal balance between acceptance and change, for which appropriate techniques are used; for specific tasks, individual techniques of TF-CBT, compassion-focused therapy, and acceptance and commitment therapy may be additionally applied. In the process of dialectical behavior therapy for PTSD, mindfulness, distress tolerance and emotional regulation skills training, interpersonal effectiveness enhancement, exposure and response prevention, opposite action, validation, and self-acceptance are utilized.

• Patients with PTSD are recommended to use Eye Movement Desensitization and Reprocessing (EMDR), lasting 6–12 sessions, to process traumatic experiences [155,156,157,158,159,160].

Level of Recommendation ALevel of Evidence 2Level of Recommendation A (Level of Evidence 2).

Comments: Eye Movement Desensitization and Reprocessing (EMDR) is a method of confrontation with traumatic experiences using targeted bilateral stimulation (via rhythmic eye movements) while simultaneously visualizing the traumatic event. Eye movements and other forms of dual-attention stimulation (in addition to eye movements, auditory stimulation or tapping on various parts of the body can be used) provide simultaneous desensitization and cognitive restructuring, as well as the integration of traumatic memories and a reduction in PTSD symptom severity. This is an individual psychotherapy method lasting 6–12 sessions, which can be conducted consecutively every day. F. Shapiro, the author of the method, is based on the premise that emotional trauma can disrupt the information processing system, causing it to persist in a form dictated by the traumatic experience and contributing to the formation of intrusive symptoms of post-traumatic syndrome. Eye movements (as well as other alternative stimuli) used in EMDR activate the information-processing system and restore its equilibrium. Psychotherapy consists of 8 sequential phases: 1. History taking, 2. Preparation, 3. Assessment, 4. Desensitization, 5. Installation, 6. Body scan, 7. Closure, 8. Re-evaluation.

If patients with PTSD are diagnosed with comorbid mental disorders, appropriate psychotherapeutic methods should be used in their treatment.

3.4. Other Treatment

• Patients with panic disorder (PD), especially treatment-resistant forms, are recommended to receive transcranial magnetic stimulation to stabilize their condition [161].

Level of Recommendation BLevel of Evidence 2Level of Recommendation B (Level of Evidence 2)

Comments: in patients with an inadequate response to pharmacotherapy, transcranial magnetic stimulation may be used as a third-line therapy

4. Medical Rehabilitation and Sanatorium-Resort Treatment

(in accordance with Order No. 103n of the Russian Ministry of Health dated February 28, 2019)

• Patients with PTSD are recommended to undergo rehabilitation measures in order to shorten the duration of temporary disability, promote early socialization in society, and improve quality of life [162,163,164,165,166,167,168,169].

GCR ALEL 1Grade of Recommendation A (Level of Evidence 1).

• Patients with PTSD are recommended to undergo medical and psychological rehabilitation to correct residual psychopathological symptoms, shorten the period of social and occupational recovery, and reduce stigmatization [170].

Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).

Comments: Rehabilitation measures are aimed at forming or restoring cognitive, motivational, emotional, and adaptive personal resources that were deficient or lost during the illness. They are most effectively carried out by a multi-professional team including a psychiatrist, psychotherapist, medical psychologist, and social work specialist. Psychoeducation, cognitive behavioral psychotherapy, socio-centered and psycho-centered supportive psychotherapeutic methods are carried out, including interventions aimed at maintaining compliance. Psychotherapy and rehabilitation measures can be delivered in individual, group, or family formats, consisting of 15–20 procedures.

• Patients with PTSD are recommended to receive early psychological intervention (by a clinical psychologist and/or psychotherapist) in the intensive care unit to reduce the risk of developing PTSD, anxiety, and depressive disorders [171].

GPP BLOE 3Grade of Recommendation B (Level of Evidence – 3).

Comments: Early psychological intervention in the intensive care unit can reduce the risk of developing post-traumatic stress disorder, anxiety, and depression, which may manifest within 12 months after discharge from the ICU.

• Patients with PTSD are recommended to undergo psychosocial rehabilitation to normalize daily functioning, improve social functioning (including family functioning), and enhance quality of life [172,304].

GRL ALEL 2Grade of Recommendation – A (Level of Evidence – 2).

Comments: family, social-psychological, and occupational supportive psychotherapy and/or clinical-psychological correction are applied; clinical-psychological and psychosocial training, family clinical-psychological counseling, and clinical-psychological adaptation are conducted, comprising 15–20 procedures. Interventions can be delivered in individual and group formats. It is advisable to perform individually tailored adaptation of existing clinical-psychological rehabilitation programs taking a personalized approach for each specific patient.

• Patients with PTSD are recommended to start early physical therapy (exercise therapy), physical exercises, and metered physical loads to increase the functional plasticity of the brain [164,165,166,167,168,169,170,171,172,173,174,175,176].

GCR ALEL 1Grade of Recommendation A (Level of Evidence 1).

Comments: a positive effect of physical exercise and physical activity on the severity of PTSD symptoms was noted—reduction of depression and anxiety symptoms, poor sleep quality, decreased substance abuse, and improved quality of life.

Physical exercise. Combines breathing with various movements that increase chest excursion. Breathing is combined with lateral torso bends and turns, maximal use of accessory respiratory muscles, breathing against resistance, exercises for relaxation of the shoulder girdle, arms, and torso (swinging arm movements, forward torso bends, uttering buzzing, whistling, and hissing sounds, etc.). Sessions lasting 15–20 minutes are carried out 2–3 times a week for at least 4 weeks.

Breathing exercises. Resistive expiration. After a sufficiently deep breath, exhale as slowly as possible through a tube into water. The exercise is repeated 4–5 times a day for 10–15 minutes.

Diaphragmatic breathing. Starting position: lying on the back. On the count of 1–2–3, take a powerful, prolonged, deep exhalation involving the abdominal muscles (pulling in the abdomen strongly); on the count of 4, take a diaphragmatic inhalation, pushing the abdomen out as far as possible. Then, rapidly contract the abdominal muscles and cough dully. The exercise is performed lying, sitting, standing, during running or walking.

• Patients with PTSD are recommended repetitive transcranial magnetic stimulation (rTMS) to relieve cortical foci of excitation [177,178,179,180,181,182,183].

GRL ALEL 2Grade of Recommendation – A (Level of Evidence – 2).

Comments: repetitive transcranial magnetic stimulation (rTMS) at a frequency of 20 Hz is applied to the right or left dorsolateral prefrontal cortex, 1600 pulses per session (40 trains of 2 seconds with an inter-train interval of 28 seconds). Course: 10 sessions. A reduction in PTSD symptoms, significant mood improvement after rTMS of the left dorsolateral prefrontal cortex, and a significant decrease in anxiety after rTMS of the right dorsolateral prefrontal cortex are observed.

• Patients with PTSD are recommended biofeedback therapy technologies to train brain self-regulation without the use of external stimulation [162,163,184,185,186,187,188].

GOR ALOE 1Grade of Recommendation – A (Level of Evidence – 1).

Comments: the use of a non-invasive form of neurofeedback (biological feedback therapy), regardless of the neuroimaging type (using electroencephalography (EEG) and real-time functional magnetic resonance imaging (fMRI) methods) for the purpose of training brain self-regulation without external stimulation. Neurofeedback includes a brain-computer interface that provides real-time feedback on brain activity, which patients learn to regulate using a "closed-loop" paradigm. The neural signal is returned to the person as an auditory or visual signal. Therapy is performed daily, procedure duration is 15–20 minutes, with 10–12 procedures per course.

• Patients with PTSD are recommended transcranial direct current stimulation for the correction of cognitive and emotional impairments [189,190].

GCR ALoE 2Grade of Recommendation A (Level of Evidence – 2).

Comments: transcranial exposure (galvanization, micropolarization) with a constant continuous electric current alters cortical excitability via subthreshold modulation of resting neuronal membrane potentials using a weak (1–2 mA) direct electric current. Stimulation is recommended daily for 20–30 minutes, with a course of 10–15 procedures.

• Patients with PTSD are recommended audiovisual polysensory relaxation (non-selective phototherapy) to activate the extraocular photoneuroendocrine system and restore subcortical brain activity [191,192,193,194,305].

GCP BLoE 2Grade of Recommendation – B (Level of Evidence – 2).

Comments: irradiation of the face with continuous optical radiation is carried out, duration: 10 minutes, daily; course: 7–10 procedures.

• Patients with PTSD are recommended exposure to visible range radiation to alter the body's adaptive-behavioral status and reduce the level of depression [194].

GRL ALEL 2Grade of Recommendation – A (Level of Evidence – 2).

Comments: the ocular method of exposure to red radiation (wavelength 0.628 µm) on the visual organ is used in a continuous mode according to a stable method. Procedure duration: 30 minutes, 2 times a week, course: 15 procedures.

• Patients with PTSD are recommended exposure to visible range radiation to stabilize emotional state and increase overall tone [195,196].

GCR ALoE 2Grade of Recommendation A (Level of Evidence – 2).

Comments: a course of 4 weeks of daily use of bright white light (illuminance: 10,000 lux) for 30 minutes a day is recommended.

• Patients with PTSD are recommended hydrotherapy for the correction of asthenoneurotic and immunosuppressive syndromes [197,198].

GCR BLOE 3Grade of Recommendations — B (Level of Evidence — 3).

Comments: Medicinal fresh-water baths. Performed at a temperature of 38 °C, daily or every other day for 10–15 minutes, course: 10–18 procedures. Repeat course after 1–2 months.

Medicinal aromatic baths. Various extracts are used. Procedure duration is 10–15 minutes for pine needle baths, 8–10 minutes for turpentine baths, daily, course: 10 procedures.

Medicinal contrast baths. Performed with alternate immersion in water at 38–42 °C (2–3 minutes) and 15–25 °C (1 minute, including for nervous system toning as the final immersion in this procedure), 3–6 transitions, course: 8–10 procedures.

Medicinal shower. Descending showers are used—rain and needle showers of cold (18–20 °C) and hot (40–42 °C) temperatures at medium pressure are prescribed for 3–7 minutes; these showers may be used with alternating cold and hot water supply (15:30 s respectively); jet showers (Charcot and Scottish showers with a pressure of 150–250 kPa, as well as circular—100–150 kPa) at the same temperature are prescribed for 3–5 minutes, course: 8–10 procedures.

• Patients with PTSD are recommended therapy using virtual reality technologies to increase resistance to the perception of psychotraumatic stimuli [199,200,201,202].

GPP ALOE 1Grade of Recommendation A (Level of Evidence – 1).

Comments: virtual reality allows engaging patients in multisensory virtual environments (especially in the interactive virtual reality variant combined with physical loads), specially adapted to stimuli they fear in an individual and controlled manner, which leads to more active patient participation and is used within combined gamified psychotherapy and exposure therapy. This method provides an opportunity to correct the patient's perception of psychotraumatic stimuli. Procedures are performed daily or every other day, with a course of 10–15 procedures lasting 15–25 minutes.

• Patients with PTSD are recommended the use of telehealth/telerehabilitation technologies to increase the accessibility of rehabilitation measures [203,204,205].

GPP ALOE 1Grade of Recommendation A (Level of Evidence – 1).

Comments: cognitive-behavioral therapy technologies and internet-based neurocognitive training are used. Therapy modules can be accessed online via a computer or a smartphone/tablet app. The duration of the recommended course is 8–10 procedures.

• Patients with PTSD are recommended health resort treatment to restore the balance of inhibitory and activating processes in the cerebral cortex [206,207,306].

Level of Evidence CGrade of Recommendation 4Level of Evidence – C (Grade of Recommendation – 4).

Comments: Health resort treatment includes air exposure, heliotherapy, and thalassotherapy methods.

Round-the-clock aerotherapy. Procedures involve the patient staying in the fresh air for as long as possible (including sleep in open climate pavilions). The duration of exposure is determined by the cold load at a fixed equivalent-effective temperature (EET). For course-based procedures, moderate (up to 3–4 hours) and intensive (up to 6–8 hours) exposure modes are used, course: 10–12 procedures [206,207].

Heliotherapy. Heliotherapy is carried out according to weak and moderate regimens, course: 12–24 procedures.

Thalassotherapy. Prescribed according to a moderate (100–140 kJ/m2) or intensive (140–180 kJ/m2) cold load regimen at a water temperature of not lower than 18 °C and 16 °C, respectively, with the calculation of bathing duration using a table [201,202].

• Patients with PTSD are recommended reflexology for central nervous system disorders to relieve persistent agitation [208,209,210,211,212,213].

GOR ALOE 1Grade of Recommendation – A (Level of Evidence – 1).

Comments: methods of classical acupuncture are used in combination with auricular and superficial reflexology. The procedure is performed using the inhibitory method, starting with general points only, with the gradual inclusion of local points. If there is no effect, the inhibitory method is applied on the affected side and the excitatory method on the healthy side. The duration of the course is 8–12 procedures.

5. Prevention and Dispensary Observation

Primary and secondary preventive measures for PTSD are distinguished. Primary preventive measures are carried out in the period preceding the potential exposure to a traumatic factor, i.e., before the person experiences the traumatic event. Secondary preventive measures are carried out in the period immediately following the exposure to the traumatic factor, i.e., implemented as closely as possible to the moment of the traumatic experience and during the first three months after the experienced traumatic event (early interventions).

• Primary preventive measures are recommended among the general population to reduce the risk of PTSD [214,215,216,217,218,219,220,221,222,223].

GGR ALOC 2Grade of recommendation A (Level of evidence 2).

Comments: Primary prevention measures include the implementation of activities preceding the occurrence of potential traumatic experiences in a person's life. There is no specific prevention to prevent the development of PTSD. PTSD prevention consists of implementing the principles of a healthy lifestyle, measures aimed at maintaining mental health among the population, and limiting alcohol and psychoactive substance use.

a) Non-psychological and non-pharmacological preventive measures for adults.

In the field of mental health in domestic practice, building a prevention system takes the form of psychological education of the population.

Psychological education is an active form of psychological prevention, the main tasks of which are:

- broadening horizons in the field of psychological knowledge about mental health and psychological well-being;

- building knowledge about the characteristics of emotional states and mechanisms of experiencing traumatic experience, criteria for the necessity of seeking medical and psychological help;

- introducing the concepts of the value of psychological hygiene, physical [224,225], social [217,218,226] and cognitive activity [219,220], which reduce the risk of developing comorbid conditions for traumatic experience;

- forming ideas about the value of physical activity, which is directly related to the neurobiological mechanisms of the influence of traumatic experience.

b) Pre-incident preparedness

For specialists who, due to their professional activities, will be exposed to traumatic stress factors (high-risk specialists and emergency response personnel: firefighters, rescuers, ambulance doctors, military personnel, etc.), psychological prevention measures can be implemented, including training events aimed at:

- informing about the features and patterns of reacting to events and conditions of professional activity and situations beyond the normal range;

- building self-regulation skills, including using biofeedback [221], attention control and management [222,226].

The low level of evidence is associated with the minimal available number of conducted studies.

• For individuals facing extreme, catastrophic stress, secondary preventive measures are recommended to reduce the risk of PTSD [224,225,226,227].

RG CLE 5Recommendation Grade C (Level of Evidence 5).

Comments: Secondary prevention measures can be implemented after exposure to a traumatic factor (occurrence of a traumatic event) meeting the criteria that potentially lead to the formation of PTSD (suddenness, subjectively experienced threat to life, loss). In domestic practice, secondary prevention can be conditionally designated by two areas partially interconnected by content and at the same time being universal recommendations for survivors of a traumatic event: emergency psychological aid and psychological education. Emergency psychological aid (EPA) also includes informational-psychological support and individual psychological help.

Emergency psychological aid (Emergency psychological aid) is an integral system of measures aimed at optimizing the current mental state, including both separate special methods of psychological intervention and the organization of a special environment that helps reduce the intensity of the impact of a traumatic event on a person. EPA can be provided to a person as closely as possible in time from the moment of exposure to the traumatic event.

The tasks of this type of psychological help include meeting the current needs of a person (information, social support, etc.), including experiencing the traumatic experience, and its goal is to preserve the psychological and physical resources of a person experiencing a traumatic event [224,225].

The preventive significance of EPA regarding delayed consequences of a traumatic situation is based on the concept of acute stress reactions, which are characterized by disorientation, decreased cognitive functions, and diverse emotional states. Such states include aggressive reactions, hysterical reactions, apathy, fear, motor agitation, and anxiety reactions. These reactions are energy-consuming, leading to neuro-psychic exhaustion, negatively affecting social adaptation, and also causing negative experiences regarding oneself [226]. Additionally, state optimization has a positive effect on susceptibility to informational-psychological support and individual psychological help.

Depending on the individual characteristics of the manifestation of the experience and reaction to the traumatic experience, a specialist may choose the implemented form of providing EPA [227].

• For individuals facing extreme, catastrophic stress, preventive measures in the form of informational-psychological support are recommended to reduce the risk of PTSD [216,218,224,225,226,227].

RG CLE 5Recommendation Grade C (Level of Evidence 5).

Comments: informational-psychological support (IPS) is a form of work aimed at informing about the characteristics of the mental state and the possible dynamics of its change, provided adapted to the current emotional state of a person, and should be provided to people facing a traumatic situation in a short time and immediately after the traumatic event, taking into account the characteristics of the psychological state at this stage (emotional states, features of cognitive functions caused by the situation of traumatic stress). IPS acts as a way to meet the deprived need for information about the situation, aimed at forming a picture of the state in which a person is, the stages and timing of its progression. IPS indirectly affects the intensity of a person's experiences, builds self-regulation skills, and also leads to a non-stigmatized attitude towards one's own state.

• Individuals facing extreme, catastrophic stress are recommended to receive individual psychological help to reduce the risk of PTSD [216,218, 219,220, 228, 229].

RG CLE 5Recommendation Grade C (Level of Evidence 5).

Comments: individual psychological help (IPH) is a form of work aimed at actualizing personal resources, accepting the current situation, searching for and actualizing coping strategies, and regulating the current mental state. One of the tools of EPA is the facilitation of emotional release of a person regarding the occurred traumatic event. The nomination of the emotional state that occurs during the provision of EPA makes it possible to reduce the impact of traumatic experiences on a person's state immediately after the event, and to actualize the resources necessary to cope with the current situation [228].

Also, maintaining social activity, building a social support network, and updating social connections can be a reasonable preventive practice for individuals experiencing a traumatic event, especially in the context of altering basic positive beliefs regarding the world and surroundings. Evidence has been found regarding the positive impact of social support, including through relationships with loved ones, on a person's ability to cope with a traumatic situation [216,217,218].

The preventive efficacy of cognitive activity regarding symptoms of re-experiencing a traumatic event is noted: one of the frequently encountered symptoms of experiencing a traumatic event is so-called intrusions, i.e., repeated intrusive memories and images of the event. Studies have been conducted based on the assumption that interfering with the visual information processing system during the acute phase of experiencing a traumatic event can reduce intrusive memories thereafter [219,220]. Thus, for example, in one study, the experimental group of patients who experienced a traumatic event and were in a medical facility immediately after the event were offered the game "Tetris". The results showed that the experimental group experienced fewer intrusive memories subsequently than the control group [229].

The low level of evidence is associated with the minimal available number of conducted studies.

• For individuals facing extreme, catastrophic stress, psychological education is recommended to reduce the risk of PTSD [230,232,233,234,235].

RG CLE 5Recommendation Grade C (Level of Evidence 5).

Comments: psychological education can be implemented by a psychologist in the form of individual information provided to a person who has experienced a traumatic event regarding common reactions that typically follow trauma, the characteristics of their mental state, possible consequences, and the dynamics of trauma-related symptom manifestations. This is done with the aim of forming an understanding of the internal picture and the normal course of the grieving/coping process, as well as developing skills to cope with certain potential symptoms. An important secondary result of this intervention will be a potential decrease in the level of subjective stigmatization, as well as facilitation of timely seeking for medical or psychological help and adherence to recommended treatment [230].

At the same time, in clinical practice, there is the term psychoeducation [231], which includes similar tasks but is implemented through the interaction between the physician and the patient [232,233,234].

Low level of evidence. Practically has no effect on PTSD severity.

• For individuals facing extreme, catastrophic stress, psychological interventions are recommended to reduce the risk of PTSD [224,225,226,227].

RG CLE 5Recommendation Grade C (Level of Evidence 5).

Comments: One of the most difficult tasks is identifying individuals in need of help, because the relationship between acute and chronic stress reactions is complex and determined by a multitude of factors that cannot be accurately indexed in the acute phase. Problems caused by experiencing pain, loss of income, interruption of work activity or the death of a loved one, and general social disadvantage that often accompanies a traumatic event can distract a person from accepting an offer for intervention. Only a small fraction of acutely traumatized individuals actually accept treatment offers [235]. In this regard, the need for ongoing monitoring of certain subgroups following trauma is of particular importance, rather than placing the emphasis solely on early intervention. Nevertheless, there are several approaches that have been accepted as effective in early interventions.

One approach to identifying groups exposed to a traumatic event may be the clinical interview method, focusing on the psychological aspects of the disorder, including the subjective experience of distress, the internal picture of the disease, available psychological resources, and individual psychological mechanisms underlying the development of symptom disorders [236].

The result of the clinical interview is the identification of adjustment disorder symptoms and the areas of their manifestation [236]. Depending on this, the psychologist can choose the strategy and form of psychological correction.

A number of studies have demonstrated the efficacy of CBT, which is supported by a large body of research data [237-253]. At the same time, other methods may be no less effective [253-263].

6. Organization of Medical Care

6.1 Organization of medical and psychological care for patients with PTSD (civilian population)

Basic principles of medical care for PTSD

· In addition to the basic treatment and rehabilitation principles of providing care to victims in a prolonged emergency situation, it is also recommended to implement the following principles when organizing care for patients with PTSD: [264,265].

1. The principle of early detection of mental disorders;

2. The principle of accessibility of psychological and psychiatric care;

3. The principle of comprehensiveness in the provision of medical and psychological care;

4. The principle of a multi-professional approach in the provision of care;

5. The principle of mobilizing one's own coping strategies;

6. The principle of dynamic support;

7. The principle of family and community support.

RG CLE 5Recommendation Grade C (Level of Evidence 5).

Comments:

1. The principle of early detection of mental disorders:

The ability to provide timely psychotherapeutic and psychiatric care in the early stages of the development of mental disorders depends on how quickly individuals affected by an emergency situation are identified. The earliest possible detection of individuals not only with fully developed mental disorders but also with subclinical-level disturbances prevents the deepening of mental disorders and their chronification, and helps prevent the development of social maladjustment. Early detection is also facilitated by broad public information campaigns regarding the causes and clinical manifestations of PTSD, medical and psychological care institutions, and the availability of hotline telephone numbers.

2. The principle of accessibility of medical and psychological care:

In an emergency situation (ES), the number of people in need of help increases sharply against the background of a limited number of specialists capable of providing the necessary assistance. It is advisable to organize "hotlines" where both patients and specialists can turn to receive psychological help and information on the organization of medical and psychological care for PTSD, as well as the institutions providing it. Moreover, the assistance should be ongoing rather than a one-time event, taking into account the potential for a prolonged course of mental disorders. The most optimal approach is to organize medical-psychiatric (psychiatric, psychotherapeutic, psychological) care directly at the place of residence of the population, in this case at the level of territorial polyclinics. Mobile forms of psychiatric, psychotherapeutic, and psychological care may also be organized.

3. The principle of comprehensiveness in the provision of medical and psychological care:

- combination of psychopharmacotherapy and psychotherapeutic methods depending on the nature of the mental disorder and the individual personality traits of the patient;

- combination of a holistic and symptomatic approach in the use of psychotherapeutic interventions, i.e., impact, on the one hand, on the abreaction and processing of experienced psychotraumatic events, and on the other hand, aimed at eliminating individual dominant psychopathological symptoms;

- involvement of physicians of other specialties for the prompt detection and treatment of comorbid somatic disorders.

4. The principle of a multi-professional approach:

The most effective approach to treating patients with PTSD is a multi-professional one. Medical and psychological (psychiatric, psychotherapeutic, psychological) care is provided to victims with the participation of specialists from various fields—general practitioners, psychotherapists, psychiatrists, clinical (medical) psychologists, social workers, and nurses. To provide effective care, it is important to train specialists—medical personnel of both specialized fields (psychiatrists, psychotherapists, medical psychologists) and physicians of other specialties. This makes it possible to implement a comprehensive approach to solving the problems of patients who have mental disorders and have been in emergency conditions for a long time.

5. The principle of mobilizing coping strategies:

The main goal of psychotherapy for individuals with PTSD who have spent a long time in emergency situations is to restore a satisfactory level of functioning. This requires certain additional ego resources or more flexible emotional, cognitive, and behavioral responses to cope with the existing consequences of psychological trauma and future stresses. An important component in overcoming experienced psychotraumatic events is the beliefs of patients. Psychotherapy and psychological correction facilitate the reassessment of what happened and form the basis for the adaptive resolution of the psychotraumatic situation.

6. Principle of dynamic support:

Very often, patients with PTSD stop visiting the doctor and/or taking medications after some improvement in their condition, which entails an exacerbation of psychopathological symptoms and clinical deterioration. As a result, patients become disappointed with the ongoing treatment and lose trust in the attending physician. When organizing psychotherapeutic care at the primary healthcare level, it becomes possible to monitor the patient's condition during their visits to the outpatient clinic or during nursing home-care rounds.

7. Family and community support:

Developing and discussing specific recommendations on behavioral tactics with patients' close relatives (spending more time with patients, involving them in general family activities, engaging them in joint labor activities) helps relatives consciously approach the patient's problems and better organize the interaction process. Involving relatives in the care process for patients who have survived severe psychological trauma significantly reduces patients' social isolation and optimizes and accelerates the process of their social rehabilitation.

Organizational model of care delivery for patients with PTSD

The organization of care for patients with PTSD is carried out in accordance with the Procedure for the Provision of Medical Care in the profile of «psychiatry».

Greater attention is required for organizing care in large-scale and prolonged emergencies, which are characterized by a large number of simultaneous casualties from psychotraumatic factors and a limited number of specialists capable of providing medical-psychological (psychiatric, psychotherapeutic, psychological) care at a professional level.

• In large-scale and prolonged emergencies, it is recommended to take into account the following principles of organizing effective medical-psychological (psychiatric, psychotherapeutic, psychological) care in order to ensure its accessibility and effectiveness:

1. Proximity – deployment of forces and resources for the provision of medical-psychological (psychiatric, psychotherapeutic, psychological) care directly in or near the disaster zone;

2. Urgency – provision of care at the earliest possible stages to купирования [sic] acute mental disorders and other types of pathology in order to prevent their further development;

3. Adequacy – substantiated choice of methods and strategies for an effective impact on «target symptoms» and «target syndromes» in order to correct and treat a wide range of reactions and conditions;

4. Staged approach – provision of care to casualties at all stages of medical evacuation according to destination;

5. Continuity – continuity and unity of methodological approaches during therapeutic and preventive measures in the disaster zone, in the immediate and remote periods after emergencies in order to relieve the psychological and psychiatric consequences of emergencies [266].

RG CLE 5Recommendation Grade C (Level of Evidence 5).

• In outpatient settings, medical care for patients with PTSD is provided in the office of a psychiatrist and/or in a psychotherapeutic office, and/or in a medical-psychological care office. If necessary, it is recommended to open temporary offices of emergency medical-psychological (psychiatric, psychotherapeutic, psychological) care to ensure its accessibility and effectiveness [267,268,269].

RG CLE 5Recommendation Grade C (Level of Evidence 5).

Comments: the basis of the office is a multi-professional (team) approach: psychiatrist – psychotherapist – clinical psychologist – social worker. The following principles are used in the office's work:

1. The principle of destigmatization of psychiatric care when working with victims.

2. The principle of constructive cooperation.

3. The principle of reasonable cooperation.

4. The principle of reasonable duration.

• In the work of Psychosocial Rehabilitation Centers (including those organized directly in the emergency or military conflict zone), psychotherapeutic centers, and mental health centers, it is recommended to focus on the staged nature of treatment and prevention of stress disorders by a multidisciplinary team of specialists: psychiatrist and/or psychotherapist, clinical psychologist, general practitioners, social worker [270,271].

RG CLE 5Recommendation Grade C (Level of Evidence 5).

Comments:

1. The first stage includes measures to prevent the development of PTSD:

- ensuring timely assistance to the population (identifying cases requiring urgent care and referring them to care delivery sites);

- interaction with other specialists, training them to recognize and identify cases of acute stress reaction, PTSD, adjustment disorders in order to refer them to specialists;

- treatment of acute stress reaction, PTSD, adjustment disorders. Timely treatment prevents the chronicity of morbid conditions and the formation of personality changes;

2. The second stage includes psychopharmacotherapy and psychotherapy for PTSD and adjustment disorders:

- diagnosis of PTSD and adjustment disorders;

- psychopharmacotherapy of PTSD and adjustment disorders;

- psychotherapy of PTSD and adjustment disorders (group and individual therapy)

3. The third stage consists of a set of measures for the psychosocial rehabilitation of individuals with PTSD:

- psychodiagnostics of personality changes in chronic PTSD and adjustment disorder;

- psychotherapy of individuals with personality changes in PTSD.

• When providing medical-psychological care in emergency situations, it is recommended to maintain continuity of care according to the scheme «psychologist of a non-medical institution – medical psychologist – psychotherapist – psychiatrist» [272,273].

RG CLE 5Recommendation Grade C (Level of Evidence 5).

Comments: it is necessary to widely inform the psychological community about the need to timely refer citizens in need of medical-psychological (psychiatric, psychotherapeutic, psychological) care to medical institutions. It is advisable to conduct training among psychologists, informing them about the signs of post-stress disorders and the possibilities of providing care to such patients.

• In emergency situations and military conflicts, the model of providing care to patients with PTSD at the level of the territorial outpatient clinic, with the active use of psychotherapeutic offices, can be recommended. This model of providing medical-psychological (psychiatric, psychotherapeutic, psychological) care to patients with PTSD has a number of advantages:

1. Availability of ready-made space for receiving patients (in this case, the outpatient clinic).

2. Overcoming stigmatization towards the psychiatric service, since the general medical network also participates in the organization of this care.

3. Bringing psychotherapeutic and psychiatric care directly to the patients' place of residence.

4. The possibility of screening patients' conditions during the first contact to identify psychopathological symptoms.

5. The possibility of providing comprehensive medical-psychiatric care to patients with PTSD.

6. Formation of a team approach in the provision of care to patients with PTSD [264,265].

RG CLE 5Recommendation Grade C (Level of Evidence 5).

Comments: to implement such a model, active inclusion in the work of psychotherapeutic offices in the outpatient clinic is required, to which a clinical (medical) psychologist is attached (in cases where there is no such office in the outpatient clinic, its prompt opening is required). Under these conditions, it becomes possible to organize a care system where at each stage of routing, specialists can adequately assess the patient's condition and provide them with care within their own competence.

At the first stage, care is provided by general medical network physicians when signs of PTSD are identified during the first contact with the patient. If patients with signs of PTSD are identified, they are referred to the psychotherapist's office.

At the second stage, in the psychotherapist's office, an in-depth diagnosis of the patients' condition is carried out and specialized psychotherapeutic care is provided to patients with PTSD. In addition, psychotherapy offices at the outpatient clinic level implement measures for the prevention of psychosomatic and personality disorders in individuals who have survived stress disorders.

The third tier of care is represented by a psychiatrist's office (of various territorial and structural affiliations), to which patients in a psychotic state, with severe behavioral and cognitive-mnestic impairments requiring psychopharmacotherapy or inpatient psychiatric care, are referred.

Indications for hospitalization in a medical organization:

1. Presence of suicide risk.

2. Presence of a risk of developing substance abuse.

3. Need for isolation from the action of the stress factor.

4. Significant severity of psychopathological disorders requiring the selection of pharmacotherapy in an inpatient setting.

5. Presence of comorbid mental disorders requiring the selection of drug therapy in an inpatient setting.

6. Poor tolerance of drug therapy.

7. Lack of social support or close relatives.

Indications for patient discharge from a medical organization:

1. Absence of suicide risk.

2. Selection of adequate and effective pharmacotherapy.

3. Absence of prominent adverse events.

4. Reduction in the severity of manifestations of psychopathological disorders.

5. Stabilization of the mental state.

6. Stabilization of the somatic state.

7. Absence of the risk of deterioration outside a medical institution in the absence of social support or a close social circle.

6.1 Organization of medical and psychological care for military personnel who have suffered combat psychological trauma

• In military personnel who have participated in combat operations (veterans), it is recommended to pay attention to and actively identify signs of the clinical picture of PTSD corresponding to the diagnostic criteria for 6B41 "Complex Post-Traumatic Stress Disorder" in ICD-11 in order to increase the accuracy of differential diagnosis and select the optimal therapy strategy [35, 274, 275].

RG CLE 5Recommendation Grade C (Level of Evidence 5).

Comments: in war veterans, along with symptoms of re-experiencing the traumatic event, avoidance of stimuli associated with the trauma, and hyperarousal, persistent changes traditionally classified as personality traits are often noted:

- pronounced mood variability with a polar ecstatic or dysphoric coloration;

- narrowing of the range of emotional manifestations, a tendency towards paroxysmal fluctuations in vital tone with "three-dimensional" (anguish, malice, fear) disorders of emotions;

- predominance of apathy, gloomy mood, withdrawal; a tendency to perceive and evaluate the environment in terms of potential danger,

- ease of occurrence of hostility under these circumstances;

- readiness for impulsive defensive reaction and switching to automatic stereotyped execution of actions habitual in a combat environment in the form of taking cover, avoidance, or aggression towards the source of danger;

- appearance of special vulnerability and sensitivity, increased sensitivity to injustice, ease of developing a sense of guilt towards comrades-in-arms;

- low susceptibility to minor stimuli or circumstances requiring additional mental expenditure, including regression of higher personality traits with a decrease in susceptibility to the suffering and death of others, withdrawal from solving moral problems, facilitating the dominance of group values;

- weakening of intrapsychic processing of impressions, reduced ability to verbalize impressions and experiences.

Such emotional changes, features of experiencing significant events, communication, and value systems are formed against the background of prolonged exposure to combat stressors and become a kind of adaptation to the realities of life at war. Along with general psychological characteristics, each specific case has its own nuances, which depend on initially inherent personality traits and the specific content of psycho-traumatic circumstances. However, the conditionally adaptive, stable personality traits acquired in war can cause further social and psychological maladaptation of veterans in peaceful life.

• For military personnel participating in combat operations or performing other operational tasks, such as peacekeeping missions, the military leadership, psychological, and medical services are recommended to carry out primary prevention measures for acute stress reactions and adjustment disorders that increase the risk of developing PTSD [35, 274].

RG CLE 5Recommendation Grade C (Level of Evidence 5).

Comments: Primary prevention measures include the implementation of activities

prior to exposure to the complex of combat psychological trauma factors:

- professional selection and dynamic monitoring of the serviceman throughout the entire service and, especially, during the preparation for a military mission, make it possible to identify servicemen with initial signs of maladaptation;

- practically and psychologically sound military-professional training, which includes, along with practicing practical combat skills and combat coordination, tactical medicine skills, as well as mastering knowledge about the causes and features of combat stress and general principles of providing care;

- training unit commanders on the impact of combat stressors on the combat effectiveness of military personnel, recognition of stress reactions, and the basic principles of providing care in the combat zone;

- efforts to create the most acceptable conditions for living, hygiene, provision of water and food, military equipment, as well as reducing the duration of combat stress exposure, which implies regular replacement of frontline units for transfer to the rear for rest, replenishment, and training in new combat means and methods.

Primary prevention reduces the subjective traumatic potential of extreme events in war, increases and preserves adaptive abilities in coping with stress, creates conditions for the implementation of the combat psychological trauma correction program, and allows active command actions to "manage" the intensity of stress impact.

Rotation of personnel in the theater of operations is recommended to be carried out no later than 6 months on the front line, and preferably every 3 months; in the case of continuous combat, for example, in an offensive, encirclement, or when performing rear-guard cover tasks - after two weeks, and in the presence of heavy casualties - even after a few days.

The low level of evidence is associated with the minimally available number

of scientific studies conducted, which is explained by the extreme difficulty of conducting them in combat conditions.

• It is recommended to conduct a brief after-action review of the mission with military personnel exposed to combat stress, led by the commander, in order to

reduce the risk of subsequent development of PTSD [35, 274, 275, 276].

GCR CLOE 4Grade of Recommendation C (Level of Evidence 4).

Comments: This variant of debriefing (leader-led after-action debriefing) in the US Army is proposed to be conducted by commanders with military personnel without obvious trauma and wounds even before medical sorting (leader-led after-action debriefing). At the same time, its difference from psychotherapy is emphasized - it is not aimed at treating psychopathological symptoms. That is, it is both a psychocorrection technique and a means of primary psychoprophylaxis. It is best to conduct this review immediately after the unit has returned to a relatively safe place, "everyone has satisfied their physiological needs and is no longer too excited." Summarizing after combat uses the approach of reconstructing events and invites everyone to present their roles and perception of everything that happened and what best fits the situation; and when people show emotions, the commander and fellow servicemen recognize and normalize them, offer to discuss them later (and then actually support the person in need on an individual basis) and further restore the sequence of actions of everyone until all facts are stated. However, when a traumatic event can cause individual or collective guilt, distrust, or anger, the commander should turn to a combat stress control specialist – a psychologist or psychiatrist. But basically, a well-conducted commander's debriefing can be the best way to manage combat stress.

It should be emphasized that this is a specific debriefing procedure carried out by a supervisor, the leader of a professional group, after completing a professional task and contains elements of social support; it is indicated exclusively for a limited contingent of persons [277].

The low level of evidence is associated with the minimally available number

scientific studies, which is explained by the extreme difficulty of conducting them in combat conditions.

• Regarding military personnel exposed to combat stress, for the purpose of secondary PTSD prevention and correction of combat stress reactions, it is advisable to implement the following organizational principles [35, 274, 275, 278, 279]:

1) maximum proximity of psychiatric care to the frontline,

2) strategy of urgency and simplicity of therapeutic measures,

3) prognostic optimism.

RG CLE 5Recommendation Grade C (Level of Evidence 5).

Comments: This pragmatic approach has become the standard of care for combat psychological trauma and is designated in US field manuals on combat stress control by the mnemonic acronym "BICEPS": Brief, Immediate, Central or Contact, Expectant, Proximal, Simple.

-    Brief – care completed within 12–72 hours;

-    Immediate – initiation of care as soon as the soldier's combat effectiveness declines, rather than after the onset of general maladaptation;

-    Central – delivery of care in a designated location, separate from medical and surgical patients, or Contact – coordination of contact between the soldier, their unit, and commanders to foster mutual communication, awareness, and interdependence for rapid reintegration;

-    Expectant – the intent to return the soldier to duty at the earliest opportunity;

-    Proximal – management provided as close as possible to the casualty's unit;

-    Simple – applying the "here and now" principle, focusing primarily on rest (sleep), hydration, nutrition, hygiene, warmth, and avoiding any intricate treatment methods.

The characteristics of combat stress reactions and PTSD in combatants that formed the basis for organizational approaches to medical and psychological care in wartime were established empirically. Given modern understandings of PTSD pathogenesis, it can be assumed that avoiding immediate evacuation for mild-to-moderate stress reactions and rapidly returning the service member to the combat environment has a positive effect through the re-integration of traumatic experience.

Repeated experience in providing wartime psychiatric care demonstrates that failing to follow the rules of combat stress prevention and management unfailingly leads to high non-battle casualty rates due to mental disorders and an increased number of veterans with psychiatric impairments post-war, whereas simply adhering to the principles of wartime psychiatric care ensures a rapid reduction in permanent losses and overall psychiatric casualties, and helps reduce long-term mental health disorders.

The low level of evidence is associated with the minimally available number

of scientific studies conducted, which is explained by the extreme difficulty of conducting them in combat conditions.

• For military personnel exposed to combat stress, in order to ensure successful secondary PTSD prevention and manage combat stress reactions, it is recommended to perform triage with therapeutic and preventive measures at various stages of medical care based on the established severity level of mental impairment [35,274,275].

RG CLE 5Recommendation Grade C (Level of Evidence 5).

Comments: A prerequisite for effective psychiatric care for military personnel exposed to combat stress is the execution of troop-level medical triage based on severity (pre-clinical, borderline, psychotic) and estimated duration of maladaptation, identifying three groups of casualties [35,274,275]:

-      Group 1 (short-term non-effective) – these service members experience pre-clinical, most often syndromically incomplete adjustment disorders or stress reactions that, with timely support, are transient and very short-lived. Care for this category of casualties should be provided at the 1st stage of psychiatric care – in close proximity to their military units based on the BICEPS principles. They are eligible to return to their units within 24 hours.

-      Group 2 (constituting active casualties) – these are casualties with short-term stress reactions requiring treatment for up to 5–7 days, receiving care at the 2nd stage of psychiatric care by Mental Health Teams (MHTs) attached to medical facilities deployed in the combat zone (e.g., Special Purpose Medical Detachment, SPMD). Care is also provided to them based on BICEPS principles.

-      Group 3 (casualties) – these are service members with prolonged and severe mental disorders requiring longer inpatient treatment and evacuation to subsequent echelons – psychiatric departments of military hospitals or, as a last resort and if more accessible, the nearest civilian psychiatric hospitals.

Efforts should be made to ensure that all psychiatric casualties undergo the 1st stage of medical care — diagnosis and psychocorrection directly within their units and subunits or medical elements near the frontline (Appendix, Figure 1). Depending on the specific situation, these may include medical and psychological support groups (MPSGs) consisting of a psychiatrist/psychotherapist and a medical psychologist, or even medical companies or medical aid posts; however, for this, short-term training (e.g., as part of a tactical medicine course) in military psychiatry for military doctors or paramedics becomes critically important, as military psychiatrist physician positions are not currently provided at the unit level. This approach makes it possible to carry out prognostic sorting already at the unit level based on assessing the degree of impairment of combat effectiveness and determining its likely duration.

• Treatment of military personnel exposed to combat stress at the 1st and 2nd stages of medical evacuation (at the troop level of medical care) for the purpose of secondary PTSD prevention is recommended with an emphasis on providing safety, rest, sleep, nutrition, with minimal medication use and limited application of short-term psychotherapy methods [35,274,275].

RG CLE 5Recommendation Grade C (Level of Evidence 5).

Comments: at the 1st stage of triage, diagnosis should be avoided as much as possible, since there are no specialist psychiatrists present, no time for differential diagnosis, and the goals are to prevent stigmatization and identification of the casualty with the patient role. At the 1st stage, treatment must be simple and brief. Agitation is managed. Ensuring sleep is mandatory, as its restoration proves essential for the regression of many stress reactions and almost always for pre-clinical reactions. The goal of pharmacotherapy is to facilitate the evacuation of patients with severe mental disorders. Psychotherapy is possible if losses are low and the number of casualties arriving at evacuation echelons is very small. An important component of care is identifying signs of traumatic brain injury and monitoring the condition of concussed personnel. The appearance of anisocoria, signs of even mild confusion, or any deterioration in the physical or mental state of a concussed person requires immediate evacuation, as untreated cases can rapidly progress to depressed consciousness and respiratory arrest. The decision to evacuate to the 2nd stage of psychiatric care is made only if prominent symptoms of stress reactions, adjustment disorders, or signs of concussion persist after 24 to 48 hours, and most importantly, combat effectiveness is clearly impaired.

The 2nd stage of care can be represented by medical units, such as special-purpose medical detachments, which must be reinforced by medical and psychological support groups (consisting of a psychiatrist and a medical psychologist), where the diagnosis of mental disorders can be made and the full scope of necessary care provided. However, it must be clearly understood that in the absence of psychiatric specialists, the special-purpose medical detachment cannot perform the functions of the 2nd stage of medical care for casualties with mental disorders. In practice, the functions of the 1st and 2nd stages of psychiatric care are often confounded, but this worsens the outcomes of combat stress reactions and increases the risk of PTSD. The choice of correction methods used at stage II is determined by the need for rapid treatment of a large number of casualties. Psychotherapy, if feasible, should be very brief, simple, and its effectiveness should depend as minimally as possible on the skill of a specific specialist. When choosing pharmacological correction agents, preference should still be given to benzodiazepine derivatives. Recently, #hydrocortisone** has been proposed as a PTSD prevention agent, which is particularly effective for preventing stress disorders in military personnel who have sustained concussions, wounds, and injuries. During the provision of care at the 2nd stage, the requirements of military discipline, subordination, and daily routine must be observed. The atmosphere should be friendly, but without external displays of excessive pity. Every incoming service member should be immediately informed of the treatment duration, explaining that the existing symptoms are temporary and will certainly resolve. If rapid (within 1–2 days) relief of psychotic and dissociative symptoms fails at this stage, it is preferable to evacuate such patients to a hospital immediately. Further delay at the military stage not only fails to improve their condition but also hinders the provision of care to other casualties. When assessing the severity of stress reactions and determining the management tactics for each specific case, data on the casualty are taken into account, including how they respond to the care provided, what will happen to their unit in the near future, and what resources are available. However, the main criterion for returning to duty is not complete recovery, but the soldier's ability to function in relation to the situation.

At the 3rd stage of psychiatric care (in the psychiatric department of a military hospital or another specialized psychiatric inpatient facility), the full required scope of psychopharmacotherapy and psychotherapy is provided for severe and protracted mental disorders, including those associated with experienced traumatic stress.

The limited use of psychotherapy methods is explained by the lack of methods that have proven their simplicity, cost-effectiveness, and reliability, the significant number of casualties at medical evacuation stages, time constraints, and the small number of specialists providing psychological, psychotherapeutic, and psychiatric care in the combat zone.

The limited use of tranquilizers is explained by the lack of consistent randomized controlled trial results for this group of drugs as means for correcting combat stress, stress reactions, and preventing PTSD.

The lack of recommendations for the use of antidepressants is explained by the scarcity of studies on their efficacy in the immediate period following traumatic stress, as well as the delayed therapeutic effect of this group of medications, which makes prescribing them at medical evacuation stages unpromising.

The lack of recommendations for the use of antipsychotics is explained by a high incidence of side effects and a negative impact on the combat readiness of service members who are expected to return to duty in the near future. Therefore, the use of antipsychotics is permissible only for controlling agitation and ensuring the evacuation of patients with psychotic disorders.

The low level of evidence is associated with the minimally available number

of scientific studies conducted, which is explained by the extreme difficulty of conducting them in combat conditions.

• For military personnel admitted to the 2nd stage of medical evacuation due to acute stress reactions and adjustment disorders, especially when combined with signs or anamnestic data of a prior concussion, after ruling out contraindications, the use of #hydrocortisone** (20–40 mg/day) orally is recommended to alleviate anxiety, neurological symptoms, and reduce the risk of subsequent PTSD [275,276,277,278,279,280,282,283,284].

GCR ALEL 1Grade of Recommendation A (Level of Evidence 1).

Comments: recent years have been characterized by interest in the use of #hydrocortisone**, which has demonstrated the ability to influence the frequency of PTSD symptoms in several randomized controlled trials. However, a significantly more pronounced effect was noted when using #hydrocortisone** as a prophylactic agent against stress disorders. Preliminary data have been obtained on the efficacy of #hydrocortisone** in the treatment of veterans who have suffered mild or moderate traumatic brain injury and exhibit PTSD symptoms. Furthermore, the efficacy of #hydrocortisone** is more noticeable when combined with cognitive behavioral therapy methods. The ability of #hydrocortisone** to affect combat stress disorders requires further study. However, it is already noted, for example, that a short, 10-day course of therapy with low doses—40 mg of #hydrocortisone** per day orally—reduces the number and severity of PTSD symptoms within the next three months in individuals who have suffered severe trauma. Thus, #hydrocortisone** prevents the development of stress disorder symptoms at lower doses than those affecting wound healing or the risk of infection.

7. Additional Information

Factors contributing to a protracted course (predictors of protracted PTSD course) [16,284,285,286,287]:

Criteria for Evaluating the Quality of Medical Care

References

Appendix A1. Working Group Composition

1. Karavaeva Tatyana Arturovna – Doctor of Medical Sciences, Associate Professor, Head of the Federal Consultative and Methodological Center for Psychotherapy of the Russian Ministry of Health, Head and Chief Researcher of the Department of Borderline Mental Disorders and Psychotherapy at the V.M. Bekhterev National Medical Research Center for Psychiatry and Neurology of the Russian Ministry of Health, Professor at the Department of Medical Psychology and Psychophysiology of St. Petersburg State University, Professor at the Department of General and Applied Psychology with Courses in Biomedical Disciplines and Pedagogy at the St. Petersburg State Pediatric Medical University of the Russian Ministry of Health, Leading Researcher at the Scientific Department of Innovative Methods of Therapeutic Oncology and Rehabilitation at the N.N. Petrov National Medical Research Center of Oncology of the Russian Ministry of Health, Vice-President of the Russian Psychotherapeutic Association (RPA), Member of the Russian Society of Psychiatrists, Head of the Working Group on the Preparation of Clinical Guidelines "Post-Traumatic Stress Disorder".

2. Vasilyeva Anna Vladimirovna – Doctor of Medical Sciences, Associate Professor, Chief Researcher of the Department of Borderline Mental Disorders and Psychotherapy at the V.M. Bekhterev National Medical Research Center for Psychiatry and Neurology of the Russian Ministry of Health, Professor at the Department of Psychotherapy, Medical Psychology and Sexology at the I.I. Mechnikov North-Western State Medical University of the Russian Ministry of Health, Member of the Coordination Council of the Russian Psychotherapeutic Association (RPA), Member of the Executive Committee of the Russian Society of Psychiatrists.

3. Idrisov Kyuri Arbievich – Doctor of Medical Sciences, Honored Doctor of the Chechen Republic, Honored Worker of Science of the Chechen Republic, Professor at the Medical Institute of the Akhmat Kadyrov Chechen State University, Chief freelance specialist psychiatrist of the Ministry of Health of the Chechen Republic, Member of the Board of the Russian Society of Psychiatrists.

4. Kovlen Denis Viktorovich – Doctor of Medical Sciences, Head of the Department of Physical and Rehabilitation Medicine at the S.M. Kirov Military Medical Academy of the Ministry of Defense of Russia.

5. Neznanov Nikolay Grigorievich – Doctor of Medical Sciences, Professor, Honored Worker of Science of the Russian Federation, Honored Worker of Higher Education of the Russian Federation, Director of the V.M. Bekhterev National Medical Research Center for Psychiatry and Neurology of the Russian Ministry of Health, Scientific Advisor of the Department of Geriatric Psychiatry at the V.M. Bekhterev National Medical Research Center for Psychiatry and Neurology of the Russian Ministry of Health, Head of the Department of Psychiatry and Narcology at the Pavlov University of the Russian Ministry of Health, Chief freelance expert in psychiatry at Roszdravnadzor, President of the Russian Society of Psychiatrists, President of the World Association for Dynamic Psychiatry (WADP, Geneva).

6. Ponomarenko Gennady Nikolaevich – Corresponding Member of the RAS, Doctor of Medical Sciences, Honored Worker of Science of the Russian Federation, Professor and General Director of the G.A. Albrecht Federal Scientific Center of Rehabilitation of the Disabled of the Ministry of Labor of Russia, Head of the Department of Physical and Rehabilitation Medicine at the I.I. Mechnikov North-Western State Medical University of the Russian Ministry of Health.

7. Radionov Dmitry Sergeevich – Junior Researcher at the Department of Borderline Mental Disorders and Psychotherapy at the V.M. Bekhterev National Medical Research Center for Psychiatry and Neurology of the Russian Ministry of Health, Member of the Russian Society of Psychiatrists.

8. Reznik Alexander Mikhailovich – Candidate of Medical Sciences, Associate Professor, Head of the Department of Psychiatry at the Medical Institute of Continuing Education of the Russian Biotechnological University (ROSBIOTECH), Researcher at the Alekseev Psychiatric Clinical Hospital No. 1 of the Moscow Healthcare Department, Member of the Russian Society of Psychiatrists.

9. Shoigu Yulia Sergeevna – Candidate of Psychological Sciences, Honored Rescue Worker of the Russian Federation, Director of the Center for Emergency Psychological Aid of the Ministry of Emergency Situations of Russia, Head of the Department of Extreme Psychology at the Faculty of Psychology of Lomonosov Moscow State University, Vice-President of the Russian Psychological Society.

Appendix A2. Methodology for Developing Clinical Guidelines

Target audience for these clinical guidelines:

1. Psychiatrists

2. Psychotherapists

3. Medical psychologists

4. General practitioners (family physicians)

Table 1.Scale for assessing levels of evidence (LE) for diagnostic methods (diagnostic interventions)

Table 2. Scale for assessing the levels of evidence (LE) for prevention, treatment, and rehabilitation methods (preventive, therapeutic, and rehabilitative interventions)

Table 3. Scale for grading grades of recommendation (GR) for prevention, diagnostic, treatment, and rehabilitation methods (preventive, diagnostic, therapeutic, and rehabilitative interventions)

Procedure for updating clinical guidelines.

The mechanism for updating clinical guidelines provides for their systematic revision at least once every three years, as well as upon the emergence of new evidence-based medicine data on the diagnosis, treatment, prevention, and rehabilitation of specific diseases, or in the presence of justified additions/comments to previously approved clinical guidelines, but no more frequently than once every 6 months.

Appendix A3. Reference Materials

1. Order of the Ministry of Health of Russia dated December 20, 2012 No. 1223n "On Approval of the Standard of Primary Medical and Social Care for Neurotic, Stress-Related and Somatoform Disorders, Post-Traumatic Stress Disorder in Outpatient Settings of a Psychoneurological Dispensary (Dispensary Department, Office)".

2. Order of the Russian Ministry of Health No. 1229n dated December 20, 2012, "On Approval of the Standard of Specialized Medical Care for Neurotic, Stress-Related and Somatoform Disorders, and Post-Traumatic Stress Disorder."

Recommended doses of medications for PTSD treatment

Level of Recommendations B (Level of Evidence 2)Level of Evidence 2Level of Recommendations B (Level of Evidence 2).

Appendix B. Physician Action Algorithms

Management algorithm for a patient with post-traumatic stress disorder

Appendix B1. PTSD treatment algorithm

1. If organizational capabilities and indications are present, combined therapy (psychotherapy + pharmacotherapy) may be prescribed immediately.

2. Paroxetine** 20-50 mg/day, sertraline** 25-200 mg/day, #fluoxetine** 20-40 mg/day) or #venlafaxine 75-225 mg/day. Efficacy is evaluated 4-6 weeks after initiation.

3. If efficacy is insufficient, it is advisable to increase the doses of the administered drug to the maximum therapeutic levels.

4. Combination with benzodiazepine derivatives is possible in the first 2-4 weeks of treatment (diazepam** 5-15 mg/day, lorazepam** 2-10 mg/day, clonazepam** 1-4 mg/day, alprazolam 0.25-4.5 mg/day, tofisopam 50-300 mg/day).

5. Combination with other anxiolytics is possible (alimemazine 15-80 mg/day, etifoxine 150-200 mg/day, hydroxyzine** 25-100 mg/day, buspirone 20-30 mg/day).

6. In each case of psychopharmacotherapy failure, it is first necessary to verify that the patient is adhering to the medication regimen.

7. If initial therapy is insufficiently effective, the 1st-line antidepressant can be replaced with another from this group, or combined therapy (psychotherapy + pharmacotherapy) can be prescribed.

8. In the absence of a response to 1st-line monotherapy and in the presence of appropriate indications, it is advisable to add #risperidone** (0.5-8 mg/day), #quetiapine** (50-300 mg/day) or #olanzapine (5-20 mg/day) to the therapy.

9. If therapy is insufficiently effective, the antidepressant can be replaced with second-line drugs – #amitriptyline** (75-150 mg/day), #imipramine** (75-250 mg/day) or #mirtazapine (30-60 mg/day). The severity of potential side effects must be kept in mind. The prescription of these drugs to patients with high suicide risk without constant monitoring is not recommended.

10. If therapy is insufficiently effective or treatment-resistant, resistance-overcoming strategies may be used:

· Monotherapy with anticonvulsants: #lamotrigine (25-500 mg/day) or #topiramate** (200-400 mg/day)

· Monotherapy with antipsychotics according to indications: #risperidone** (0.5-8 mg/day), #quetiapine** (50-300 mg/day), or #olanzapine** (5-20 mg/day).

· Transcranial magnetic stimulation of the brain;

· Use of combinations of various medicinal products according to their pharmacological effects and the patient's condition. Cautious use of experimental treatment methods.

Appendix C. Patient Information

What is post-traumatic stress disorder (PTSD)?

PTSD is a disorder that can develop after experiencing extremely severe stress that is traumatic for almost any person and exceeds the normal adaptive capacity of the psyche.

Such psychotraumatic events include threats to life, assault, torture, violence, natural and man-made disasters, military actions, terrorist acts, captivity or concentration camp confinement, witnessing the death of another person, a life-threatening illness, receiving news of the sudden or violent death of a loved one, and others.

PTSD can lead to severe mental and psychological impairments, and in some cases, somatic conditions as well.

What are the main symptoms of PTSD?

1. Re-experiencing the stressful traumatic event in the present in the form of vivid intrusive memories accompanied by fear or horror. Such involuntary memories severely disrupt mental equilibrium, making the person feel the same way, or almost the same way, as at the moment of the negative events.

2. A pronounced desire to avoid thoughts and memories of the event, or to avoid activities, situations, and people that remind of it. This may manifest as an intentional or involuntary desire to shun and protect oneself from anything that could even indirectly remind of the experienced stress.

3. A state of subjective feeling of ongoing threat, heightened anxiety, alertness, and a feeling that something terrible might happen. A sense of tension, inability to feel safe, calm, and well may arise.

4. Sleep disturbances, difficulty falling asleep due to memories, and frightening nightmares. The plots of experienced stressful situations are often repeated in dreams.

Under certain circumstances, other disorders may also develop:

· Changes in the emotional sphere – mood swings, depression, irritability, anxiety over minor things, experiencing a lack of emotions, a feeling of unreality of what is happening;

· Behavioral reactions – outbursts of rage, anger, reckless or self-destructive behavior, abuse of alcohol and other psychoactive substances;

· Negative self-perceptions – feelings of shame, guilt, humiliation or inadequacy, a feeling of emptiness, loss of the ability to experience joy or positive emotions;

· Impairments in social interaction – avoidance of or disinterest in personal relationships, lack of interest in work, loss of hobbies, difficulties in maintaining close relationships.

Symptoms usually appear within six months of the stressful event and last for at least several weeks, and sometimes months and years.

PTSD can cause significant deterioration in well-being, decreased performance, impaired interpersonal relationships, loss of motivation for professional and daily activities and self-care, loss of former interests, and a drive to avoid human contact and isolate oneself.

!!! IMPORTANT: It is important to understand that if you observe the symptoms listed above in yourself, you will not be able to "pull yourself together" through sheer willpower. You must seek help from a specialist in a timely manner. Support from loved ones is also very important during this period.

Diagnosis of post-traumatic stress disorder.

PTSD is diagnosed and treated by a psychotherapist or psychiatrist.

A preliminary diagnosis can be made by a general practitioner or neurologist.

Treatment of post-traumatic stress disorder.

PTSD treatment includes psychotherapy and the prescription of medications.

Special psychotherapeutic techniques are used aimed at processing painful experiences, correctly perceiving the traumatic experience, and restoring emotional state.

Simultaneously, psychotherapy involves activating personal resources and training in the self-regulation of mood and physical well-being. This helps one feel confident in their ability to cope with stressful situations in various circumstances.

Psychotherapy can be conducted individually or in small groups.

Drug treatment includes the use of various agents that reduce feelings of tension and anxiety, and normalize sleep and mood. Anti-anxiety medications (anxiolytics, sedatives), antidepressants, and certain others are used for this purpose.

Medical treatment – prescription, therapy adjustment, and discontinuation of drugs – is carried out exclusively by a specialist physician.

Additional Information

In addition to professional help, a person's lifestyle plays a significant role in the therapy and prevention of PTSD.

In some situations, relaxation techniques (yoga, deep breathing, muscle relaxation, and others) can bring relief. Physical activity can also help improve mood and enhance the positive effects of treatment.

For people who have experienced psychotraumatic circumstances, and especially those who have developed PTSD symptoms, it is important to make conscious efforts to counteract the drive toward self-isolation. Family and friends can offer sincere support and help in difficult situations.

Reaching out to psychological support groups and communities of people who have been through similar circumstances can be of significant benefit.

Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools

Appendix G1 PTSD Screening Questionnaire

Russian title: PTSD Screening Questionnaire

Original title: Trauma Screening Questionnaire (Brewin C. et al., 2002)

Source: Brewin, C. R., Rose, S., Andrews, B., Green, J., Tata P., Mc Evedy, C., Turne, S., and Foa E. B. Brief screening instrument for post-traumatic stress disorder. / The British Journal of Psychiatry. – 2002 – V. 181, №3. – P. 158-162.

Type (underline):

- rating scale

- index

- questionnaire

- other (please specify):

Purpose: The Trauma Screening Questionnaire (TSQ) determines the severity of clinical manifestations, disease course, core psychopathological symptoms, and clarifies the main clusters of symptoms typical for PTSD.

The Trauma Screening Questionnaire (TSQ) is a brief 10-item questionnaire reflecting intrusion and physiological arousal symptoms, used for PTSD screening. The instrument was developed and adapted at the Department of Clinical Health Psychology, University College London, in 2002.

It consists of 10 questions reflecting intrusion symptoms and physiological arousal, with yes/no response options. For a positive response, each symptom must have been experienced at least twice in the past week.

Content (template):

Instructions: This questionnaire relates to your personal reactions to a traumatic event that happened to you.

Below are some reactions that people sometimes experience after a traumatic event. Please answer "Yes" if you have experienced the following symptoms at least twice in the past week.

Key (interpretation):

If the score obtained on the questionnaire is 6 or higher, the subject should be classified as at-risk. This questionnaire has proven to be a good brief tool for identifying PTSD symptoms. However, to establish a diagnosis or verify symptoms, the results must be confirmed through a clinical interview and additional testing methods.

Appendix G2 Clinician-Administered PTSD Scale (CAPS)

Russian title: Clinician-Administered PTSD Scale for PTSD

Original title: Clinician-Administered PTSD Scale - CAPS (Weathers F. W. et al., 1992; Weathers F.W, 1993)

Source: Tarabrina N.V. Praktikum po psikhologii posttravmaticheskogo stressa — St. Petersburg: Piter, 2001. — 272 p.

Type (underline):

-rating scale

-index

-questionnaire

-other (specify)

Purpose: The Clinician-Administered PTSD Scale (CAPS) was developed in two versions (Weathers F. W. et al., 1992; Weathers F.W, 1993). The first was designed to assess the severity of current PTSD, both over the past month and throughout the post-traumatic period overall. The second version of CAPS is intended for a differentiated assessment of symptoms over the past two weeks. The methodology allows not only evaluating each symptom on a five-point scale in terms of frequency and intensity of manifestation, but also determining the validity of the obtained information.

The CAPS scale is generally used as an adjunct to the Structured Clinical Interview for DSM (SCID) for the clinical diagnosis of the severity of PTSD symptoms and their frequency. It is used if the interview diagnoses the presence of any PTSD symptoms or the disorder as a whole (Weathers F.W., Litz B.T., 1994; Blake D.D., 1995).

CAPS-1 allows assessing the frequency and intensity of individual symptoms of the disorder, as well as the degree of their impact on the patient's social and occupational functioning. This scale can be used to determine the degree of clinical improvement upon re-evaluation compared to the previous assessment, the validity of the results, and the overall symptom intensity. Whenever possible, it is advisable to use the CAPS-1 scale in combination with other diagnostic methods (self-assessment, behavioral, physiological). It must be remembered that the observation period for each symptom is 1 month. The scale questions determine the frequency of the studied symptom over the preceding month, and then assess the intensity of the symptom manifestation. The wording of key scale points can be read aloud to the patient (both for symptom frequency and intensity). This ensures the most accurate ratings.

A frequency score > 1 and an intensity score > 2, reflecting real problems associated with that symptom, can serve as the basis for concluding that the symptom is present. It is important to emphasize that criteria C, D, and E require that the symptom was not present before the trauma. The interviewer must clarify that the patient's manifestation of symptoms C, D, and E occurred specifically after the trauma. If the patient's condition met the diagnostic criteria for PTSD in the past month, it is automatically categorized as meeting the criteria for post-traumatic PTSD. CAPS-1 was translated at the Laboratory of Post-Traumatic Stress Psychology and Psychotherapy of the Russian Academy of Sciences and has been used in comprehensive PTSD studies across various cohorts; the obtained data are presented below (Tarabrina N.V. et al., 1995, 1996).

Content (template):

Assessment Form

Patient ____________________

Date ______________

Interviewer ____________

A. TRAUMATIC EVENT ____________________

B. PERSISTENT REEXPERIENCING OF THE TRAUMATIC EVENT

(1) Recurrent distressing recollections of the event

Frequency

Have you ever involuntarily, without any trigger, recalled these events? Was this only in dreams? (Exclude if memories occurred only in dreams.) How often did this happen over the past month?

0 – never

1 – once or twice

2 – once or twice a week

3 – several times a week

4 – daily or almost daily

Intensity

Taking the most severe of these instances, how intense was the distress caused by these memories? Were you forced to interrupt whatever you were doing at that moment? Are you able, if you try, to overcome these memories and get rid of them?

0 – no distress

1 – mild symptom intensity: minimal distress

2 – moderate intensity: clearly present distress

3 – high intensity: substantial distress, obvious disruption in functioning, and difficulty coping with the memories of the event

4 – very high intensity: severe, unbearable distress, inability to continue functioning, and inability to rid oneself of the memories of the event

(2) Recurrent distressing dreams of the event

Frequency

Have you had instances when you saw something that reminded you of these events, causing you to feel distressed and upset? (For example: a certain type of men for rape victims, a grove of trees or a wooded area for war veterans.) How often did this happen to you over the past month?

0 – Never

1 – once or twice

2 – once or twice a week

3 – several times a week

4 – daily or almost daily

Intensity

Taking the most severe of these instances, how upset and distressed were you, and how intense were the feelings?

0 – not at all

1 – mild symptom intensity: minimal distress

2 – moderate intensity: clearly present distress, but still manageable

3 – high intensity: significant distress

4 – very high intensity: unbearable distress

(3) Acting or feeling as if the traumatic event were recurring, including a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, even those occurring upon awakening

Frequency

Have you ever suddenly acted or felt as if the event(s) were happening all over again? How often did this happen to you over the past month?

0 – never

1 – once or twice

2 – once or twice a week

3 – several times a week

4 – daily or almost daily

Intensity

Taking the most severe of these instances, how real was this sensation? To what extent did it feel as though the event(s) were happening again? How long did it last? What did you do while it was happening?

0 – never experienced this

1 – mild symptom intensity: feeling that things are slightly more real than when simply thinking about them

2 – moderate intensity: distinct sensations with a dissociative quality, yet a close connection to the surroundings is maintained; sensations resemble daydreams

3 – high intensity: strongly dissociative sensations — the patient reports images, sounds, smells, but some connection to the surrounding world is still maintained

4 – very high intensity: sensations are completely dissociative — flashback effect, complete lack of connection with surrounding reality, possible amnesia for this episode («blackout», memory gap)

(4) Recurrent distressing dreams of the event

Frequency

Have you ever had unpleasant dreams about that event? How often has this happened to you over the past month?

0 – never

1 – once or twice

2 – once or twice a week

3 – several times a week

4 – daily or almost daily

Intensity

Taking the worst of these instances, how intense were the unpleasant, distressing feelings and discomfort caused by these dreams? Did you wake up from these dreams? (If yes, ask: «What did you feel or do when you woke up? How long did it usually take you to fall back asleep?» Listen to the account and note symptoms of panic, loud cries, body posture.)

0 – none

1 – mild symptom intensity: minimal distress, did not cause awakening

2 – moderate intensity: wakes up distressed, but falls back asleep easily

3 – high intensity: very severe distress, difficulty falling back asleep

4 – very high intensity: overwhelming distress, inability to fall back asleep

C. PERSISTENT AVOIDANCE OF STIMULI ASSOCIATED WITH THE TRAUMA AND NUMBING OF GENERAL RESPONSIVENESS (numbing) (symptoms not observed before the trauma)

(5) Efforts to avoid thoughts or feelings associated with the trauma

Frequency

Have you tried to push away thoughts about the event(s)? Have you made efforts to avoid sensations associated with the event(s) (e.g., feelings of anger, sadness, guilt)? How often has this happened to you over the past month?

0 – never

1 – once or twice

2 – once or twice a week

3 – several times a week

4 – daily or almost daily

Intensity

How great were the efforts you made to avoid thinking about that event(s) and to avoid feelings related to it (them)? (Assess all attempts at conscious avoidance, including distraction, suppression, and reducing arousal with alcohol or drugs.)

0 – no effort

1 – mild symptom intensity: minimal effort

2 – moderate intensity: some effort, avoidance is definitely present

3 – high intensity: significant effort, avoidance is certainly present

4 – very high intensity: clearly pronounced attempts at avoidance

(6) Efforts to avoid activities or situations that trigger recollections of the trauma

Frequency

Have you ever tried to avoid any activities or situations that would remind you of the event(s)?

0 – never

1 – once or twice

2 – once or twice a week

3 – several times a week

4 – daily or almost daily

Intensity:

How great were the efforts you made to avoid activities or situations associated with the event(s)? (Assess all attempts at behavioral avoidance; for example, war veterans avoiding veteran events, watching war movies, etc.)

0 – no effort

1 – mild symptom intensity: minimal effort

2 – moderate intensity: some effort, avoidance is definitely present

3 – high intensity: significant effort, avoidance is certainly present

4 – very high intensity: clearly pronounced attempts at avoidance

(7) Inability to recall an important aspect of the trauma (psychogenic amnesia)

Frequency

Have you experienced an inability to recall important circumstances of the event(s) that happened to you (e.g., names, faces, sequence of events)? Was much of what was related to the occurrence difficult for you to recall over the past month?

0 – none, clear memory of the event as a whole

1 – some circumstances of the event(s) could not be recalled (less than 10%)

2 – a number of circumstances of the event(s) could not be recalled (20–30%)

3 – a major part of the circumstances of the event(s) could not be recalled (50–60%)

4 – almost completely unable to recall the event(s) (more than 80%)

Intensity

How great were the efforts you had to make in order to recall important circumstances of what happened to you?

0 – no difficulty in recalling the events

1 – mild symptom intensity: minor difficulty in recalling the circumstances of the event

2 – moderate intensity: definite difficulty, but upon concentration, the ability to recall the event in memory is preserved

3 – high intensity: unquestionable difficulty in recalling the circumstances of the event

4 – very high intensity: complete inability to recall the event(s)

(8) Marked loss of interest in favorite activities

Frequency

Do you feel that you have lost interest in activities that were important or pleasurable to you — for example, sports, hobbies, socializing? Compared to before the event, how many types of activities have you lost interest in over the past month?

0 – no loss of interest at all

1 – loss of interest in certain activities (less than 10%)

2 – loss of interest in several activities (20–30%)

3 – loss of interest in a large number of activities (50–60%)

4 – loss of interest in almost everything (more than 80%)

Intensity

In the worst case, how profound or strong was the loss of interest in these activities?

0 – no loss of interest at all

1 – mild symptom intensity: only minor loss of interest, does not preclude experiencing pleasure during activities once they are initiated

2 – moderate intensity: definite loss of interest, but still maintains some sense of pleasure from the activity or activities

3 – high intensity: very significant loss of interest in activities

4 – very high intensity: complete loss of interest, engages in no activity whatsoever

(9) Feeling of detachment or estrangement from others

Frequency

Have you felt detached or cut off from others? Did this state differ from what you felt before the event(s) occurred? How often did you feel this way over the past month?

0 – never experienced this

1 – rarely (less than 10% of the time)

2 – sometimes (20–30%)

3 – often (50–60%)

4 – almost always or constantly (more than 80%)

Intensity

In the worst case, how intense was your feeling of detachment or lack of connection with others? Who, if anyone, remained close to you?

0 – None

1 – Mild symptom intensity: occasionally feels "out of step" with others

2 – Moderate intensity: a definite sense of detachment, but some interpersonal connections and a sense of belonging to the world around remain

3 – High intensity: a significant feeling of detachment or alienation from most people, with the ability to interact with only one person

4 – Very high intensity: feels completely cut off from other people, maintains no close relationships with anyone

(10) Restricted affect, e.g., inability to experience feelings of love

Frequency

Have there been times when you were "numb" (found it difficult to feel emotions such as love or happiness)? Did this state differ from how you felt before the event(s) occurred? How often did you feel this way during the past month?

0 – never experienced this

1 – rarely (less than 10% of the time)

2 – sometimes (20–30%)

3 – often (50–60%)

4 – almost always or constantly (more than 80%)

Intensity

In the worst case, how intense was your feeling of "emotional numbness"? (Include observations of affect during the interview in your rating.)

0 – No feeling of numbness

1 – Mild symptom intensity: such a feeling is present, but minimal

2 – Moderate intensity: clear feeling of numbness, but the ability to experience emotions is still preserved

3 – High intensity: significant feeling of numbness regarding at least two primary emotions – love and happiness

4 – Very high intensity: feels a complete absence of emotions

(11) Sense of a foreshortened future, e.g., not expecting to get a promotion, get married, have children, or live a long life

Frequency

Have you ever felt that there was no need to make plans for the future, that for some reason you "have no tomorrow"? (If yes, clarify whether there is a real risk, such as life-threatening medical diagnoses.) Did this state differ from how you felt before the event(s) occurred? How often did you feel this way during the past month?

0 – never experienced this

1 – rarely (less than 10% of the time)

2 – sometimes (20–30%)

3 – often (50–60%)

4 – almost always or constantly (more than 80%)

Intensity

In the worst case, how intense was the feeling that you would not have a future? How long do you think you will live? What reasons do you have for assuming that you will die prematurely?

0 – No sense of a foreshortened future

1 – Mild symptom intensity: minor feelings regarding a shortened life perspective

2 – Moderate intensity of symptom: a definite sense of a shortened life perspective is present

3 – High intensity of symptom: significantly expressed feelings of a shortened life perspective, certain premonitions about life expectancy may be present

4 – Very high intensity of symptom: all-consuming feeling of a shortened life perspective, absolute conviction of premature death

D. PERSISTENT SYMPTOMS OF INCREASED AROUSAL (not present before the trauma)

(12) Difficulty falling or staying asleep

Frequency

Have you had any problems falling asleep or staying asleep normally? Does this differ from how you slept before the event(s)? How often did you have sleep difficulties in the past month?

0 – never

1 – once or twice

2 – once or twice a week

3 – several times a week

4 – Every night (or almost every night)

Difficulty falling asleep?

Yes No

Waking up during the night?

Yes No

Very early awakening?

Yes No

Number of hours of sleep (without waking) per night___________

Desired number of hours of sleep for the subject_______

Intensity

(Ask clarifying questions and assess all listed sleep disturbances.) How long does it take you to fall asleep? How often do you wake up during the night? How many consecutive hours do you sleep without waking each night?

0 – No sleep problems

1 – Mild symptom intensity: falling asleep is somewhat difficult, some difficulty maintaining sleep (sleep loss up to 30 minutes)

2 – Moderate intensity: definite sleep disturbance – clearly expressed increased sleep onset latency or difficulty maintaining sleep (sleep loss – 30–90 minutes)

3 – High intensity: significant prolongation of sleep onset time or major difficulty maintaining sleep (sleep loss – 90 minutes to 3 hours)

4 – Very high intensity: very long sleep latency, insurmountable difficulty maintaining sleep (sleep loss greater than 3 hours)

(13) Irritability or outbursts of anger

Frequency

Have there been periods when you felt unusually irritable or showed feelings of anger and behaved aggressively? Does this state differ from how you felt or acted before the event(s)? How often did you experience such feelings or behave this way in the past month?

0 – never

1 – once or twice

2 – once or twice a week

3 – several times a week

4 – daily or almost daily

Intensity

How intense was the anger you experienced and how did you express it?

0 – Neither irritability nor anger

1 – Mild symptom intensity: minimal irritability, raising one's voice when angry

2 – Moderate intensity: clear presence of irritability, easily starts arguing when angry, but "cools down" quickly

3 – High intensity: significant irritability, verbal or behavioral aggressiveness when angry

4 – Very high intensity: uncontrollable anger accompanied by episodes of physical violence

(14) Difficulty concentrating

Frequency

Did you find it difficult to concentrate on an activity or something around you? Has your ability to concentrate changed since this event(s) happened? How often did you experience difficulty concentrating during the past month?

0 – Not at all

1 – Very rarely (less than 10% of the time)

2 – Sometimes (20–30% of the time)

3 – Most of the time (50–60%)

4 – almost always or constantly (more than 80%)

Intensity:

How difficult was it for you to concentrate on anything? (Take your observations during the interview into account when rating this item.)

0 – No problem at all

1 – Mild intensity: minor effort was required to concentrate

2 – Moderate intensity: definite loss of ability to concentrate, but can concentrate with effort

3 – High intensity: significant impairment of function, even with special effort

4 – Very high intensity: complete inability to focus and concentrate attention

(15) Hypervigilance

Frequency

Have you had to be especially alert or watchful even when there was no obvious need for it? Does this differ from how you felt before the event(s)? How often were you alert or watchful in the past month?

0 – Not at all

1 – Very rarely (less than 10% of the time)

2 – Sometimes (20–30% of the time)

3 – Most of the time (50–60%)

4 – almost always or constantly (more than 80%)

Intensity

How great is the effort you put into knowing everything that is happening around you? (Use your observations during the interview when rating this item.)

0 – symptom absent

1 – mild symptom intensity: minimal manifestations of hypervigilance, slightly increased curiosity

2 – moderate intensity: definitely present hypervigilance, wariness in public places (e.g., choosing a safe spot in a restaurant or movie theater)

3 – high intensity: significant manifestations of hypervigilance, the subject is very wary, constantly monitoring surroundings for danger, exaggerated concern for their own safety (as well as that of their family and home)

4 – very high intensity: hypertrophied vigilance, efforts to ensure safety require significant time and energy and may include active checking behaviors; significant wariness during the conversation

(16) Exaggerated startle response («startle» reaction to a sudden stimulus)

Frequency

Have you experienced a strong startle reaction to loud unexpected sounds (e.g., car exhausts, fireworks, a slamming door, etc.) or to something you suddenly saw (e.g., movement caught in your peripheral vision – «out of the corner of your eye»)? Is this different from how you felt before the event(s)?

0 – never

1 – once or twice

2 – once or twice a week

3 – several times a week

4 – daily or almost daily Intensity

In the worst-case scenario, how severe was this startle reaction?

0 – symptom absent: no startle reaction

1 – mild symptom intensity: minimal startle reaction

2 – moderate intensity: definite startle reaction to a sudden stimulus, «jumping»

3 – high intensity: significant startle reaction, continued arousal after the initial reaction

4 – very high intensity: extremely pronounced startle reaction, overt defensive behavior (e.g., a war veteran who «hits the dirt»)

(17) Physiological reactivity upon exposure to circumstances resembling or symbolizing various aspects of the traumatic event

Frequency

Have you noticed certain physiological reactions when encountering situations that remind you of the event(s)? (Listen for reports of symptoms such as rapid heartbeat, muscle tension, trembling hands, sweating, but do not ask leading questions about the symptoms.) How often did they occur in the past month?

0 – never

1 – once or twice

2 – once or twice a week

3 – several times a week

4 – daily or almost daily

Intensity

In the worst-case scenario, how intense were these physiological reactions?

0 – symptom absent

1 – mild symptom intensity: minimal reaction

2 – moderate intensity: clear physiological reaction, some discomfort

3 – high intensity: intense physiological reaction, severe discomfort

4 – very high intensity: dramatic physiological reaction, prolonged subsequent arousal

Was there any period after the trauma when the symptoms I just asked you about troubled you significantly more than during the past month?

Yes No

Did this period (or periods) last for at least one month?

Yes No

Approximately when did this period (or periods) start and end?

______________________________________________________________

Key (interpretation):

Mean CAPS scores (Tarabrina, 2001)

F — symptom frequency, I — symptom intensity, T — total score.

Appendix G3 Structured Clinical Interview for DSM (SCID) – Structured Clinical Interview for DSM (SCID), Davidson, Smith, Kudler)

Russian title: Structured Clinical Interview for Diagnostic and Statistical Manual (SCID)

Original title: Structured Clinical Interview for DSM (SCID), Davidson, Smith, Kudler, 1989);

Source: Post-traumatic stress disorder / ed. by V.A. Soldatkin; Rostov State Medical University of the Russian Ministry of Health. – Rostov-on-Don: Rostov State Med. Univ. Press, 2015. – 624 p.

Type (underline):

-rating scale

-index

-questionnaire

-other (specify)

diagnostic interview

Purpose: The Structured Clinical Interview for DSM (SCID) includes a series of diagnostic modules (question blocks) that provide diagnosis of mental disorders according to DSM-IV criteria (affective, psychotic, anxiety, substance-induced, etc.). The interview design allows working independently with any module, including the PTSD module. Each module provides clear instructions enabling the examiner to switch to a conversation on another question block if necessary. Thus, upon diagnostically significant responses to questions targeting Criterion A – the presence of a traumatic event in the respondent's history – the interviewer asks questions from subsequent blocks to obtain information on the severity level of symptoms related to other PTSD criteria.

The interview design allows working independently with any module, including the PTSD module. In each module, clear instructions are provided to allow the examiner to switch to a conversation on another question block as needed. If necessary, independent experts may be involved to establish a final diagnosis.

Content (template):

Module I. «Post-traumatic Stress Disorder»

Instructions. During the interview, ask the patient the specified questions, circle YES or NO. If NO with an arrow is circled, the interview ends, and the absence of PTSD is stated («Current PTSD — NO» at the end of the module).

Key (interpretation)

Affirmative answers to questions targeting diagnostic Criterion A give the interviewer grounds for further discussion on the following blocks of questions targeting diagnostic criteria: B – the traumatic event is persistently re-experienced; C – persistent avoidance of stimuli and numbing of general responsiveness associated with the trauma; D – persistent symptoms of increased arousal; E – duration of the disorder (more than 1 month); F – the disorder causes clinically significant severe emotional distress or impairment in social, occupational, or other important areas of functioning. If necessary, independent experts may be involved to establish a final diagnosis. The authors of the method provide for the possibility of its further modifications depending on specific research objectives.

Appendix G4 Impact of Event Scale-Revised (IES-R)

Russian title: Impact of Event Scale (IES)

Original title: Impact of Event Scale-R – IES-R (Horowitz M. J., Wilner N. et. al., 1979)

Source: Horowitz, M. Wilner, N. & Alvarez, W. (1979). Impact of Event Scale: A measure of subjective stress. Psychosomatic Medicine, 41, 209-218. Tarabrina N.V. Praktikum po psikhologii posttravmaticheskogo stressa — SPb: Piter, 2001. — 272 p.,

Type (underline):

-rating scale

-index

-questionnaire

-other (specify)

Purpose: The Impact of Event Scale-Revised (IES-R) is a clinical test method aimed at identifying symptoms of post-traumatic stress disorder and assessing their severity.

The scale consists of 22 items divided into three subscales: "intrusion", "avoidance", and "hyperarousal". Each item is rated as "not at all" (0 points), "rarely" (1 point), "sometimes" (3 points), or "often" (5 points).

Processing of the IES-R data is carried out according to the key:

"intrusion" subscale (IN): sums the scores of items 1, 2, 3, 6, 9, 16, 20; – allows identifying nightmares and intrusive thoughts associated with the traumatic event in the subject

"avoidance" subscale (AV): sums the scores of items 5, 7, 8, 11, 12, 13, 17, 22; – allows identifying avoidance symptoms in the subject, including attempts to mitigate or avoid experiences related to the impact of the crisis event

"physiological arousal" subscale (AR): sums the scores of items 4, 10, 14, 15, 18, 19, 21; – allows identifying anger and irritability, an exaggerated startle response, psychophysiological arousal caused by memories of the event, and insomnia in the subject.

All items have a direct scoring value.

The questionnaire is designed to study the presence, severity, and symptomatic structure of post-traumatic stress disorder. The scale has proven to be a reliable, valid instrument that has undergone cross-cultural adaptation. The scale can be included in a battery of psychodiagnostic methods for working with individuals who have or are suspected of having PTSD.

Content (template):

Instructions

Using this scale, please indicate the extent to which you agree or disagree with the given statement. Provide only one answer for each statement: Not at all, Rarely, Sometimes, Often. Please note that the listed symptoms refer to how you have been feeling over the past week.

Key (interpretation):

"Intrusion" subscale: sum of scores for items 1, 2, 3, 6, 9, 16, 20.

"Avoidance" subscale: sum of scores for items 5, 7, 8, 11, 12, 13, 17, 22.

"Physiological arousal" subscale: sum of scores for items 4, 10, 14, 15, 18, 19, 21.

Appendix G5 Mississippi Scale for Combat-Related Posttraumatic Stress Disorder (Mississippi Scale)

Russian title: Mississippi Scale for Post-traumatic Stress Disorder

Original title: Mississippi Scale (Keane, Caddell, Taylor, 1988)

Source: Tarabrina N.V. Praktikum po psikhologii posttravmaticheskogo stressa — St. Petersburg: Piter, 2001. — 272 p.

Type (underline):

-rating scale

-index

-questionnaire

-other (specify)

Purpose: The Mississippi Scale for Posttraumatic Stress Disorder (Mississippi Scale) is a clinical test method originally developed in 1987 by T.M. Keane et al. for diagnosing PTSD in military personnel who had served in combat zones. In 1995, a civilian version of the scale was developed and published, validated on a sample of civilians with an established diagnosis of PTSD.

The questionnaire consists of 35 items in the "military" version and 39 items in the "civilian" version. Thirty items form three main scales corresponding to the three PTSD symptom groups according to DSM-III: 11 items of the first scale describe intrusion symptoms, 11 items of the second scale describe avoidance symptoms, and 8 items of the third scale describe arousal symptoms. The remaining five items describe symptoms related to guilt and suicidal tendencies. Population studies have demonstrated high internal consistency for both the military (0.94) and civilian (0.86) versions of the scale. The scale has 87% sensitivity and 63% specificity in diagnosing PTSD among psychiatric patient populations.

Answers to the questions are given using a Likert scale. Despite the grouping of questions into four subscales, only a single total score is calculated. Some of the questions have reversed scoring values, which helps reduce response bias or random completion of the form.

Content (template):

Civilian version form

Questionnaire text

Name____________________

Gender_______Age______________

Marital status______________ Children______________ Profession_______________________________________________

Weight___________ Height____________

Below are statements summarizing various experiences of people who have survived severe, extreme events and situations. Each statement has a scale from "1" to "5". Using this scale, please indicate the extent to which you agree or disagree with the given statement. Give only one answer for each statement: Not at all true, Sometimes true, To some degree true, True, Exactly true

Military version form

Questionnaire text

Name____________________

Gender_______Age______________

Marital status______________ Children______________

Occupation______________________________________

Weight___________ Height____________

Below are statements summarizing various experiences of individuals who participated in combat operations. Each statement has a scale from "1" to "5". Using this scale, indicate the extent to which you agree or disagree with the statement. Give only one answer for each statement: Completely false, Sometimes true, Somewhat true, True, Completely true

Key (interpretation):

Each match with the key is scored as one point:

Civilian version

Military version

Appendix G6 Combat Exposure Scale (CES) (T.M. Keane, J.A. Fairbank, J.M. Caddell, R.T. Zimmering, K.L. Taylor, C.A. Mora).

Russian title: "Combat Exposure Scale" by T. Keane

Original title: Combat Exposure Scale

Source: Post-traumatic stress disorder / edited by V.A. Soldatkin; SEI HVE RSMU of the Russian Ministry of Health. – Rostov-on-Don: RSMU Publishing House, 2015. – 624 p.

Type (underline):

-rating scale

-index

-questionnaire

-other (specify)

Purpose:

The Combat Exposure Scale (CES) by T. Keane is designed to assess quantitative parameters of the frequency and duration of military personnel's participation in various extreme situations under combat conditions. To assess the impact of combat exposure intensity on the psychological state of military conflict participants, it is recommended to use this methodology in conjunction with other tools, such as the "Clinician-Administered PTSD Scale" (CAPS, Weathers F.W. et al., 1992; Weathers F.W., 1993), the "Mississippi Scale for Combat-Related Posttraumatic Stress Disorder" (military version), the "Impact of Event Scale-Revised" (IES-R), etc.

The method includes 7 questions concerning the nature and duration of the subject's exposure to combat conditions. Below each question is a scale ranked from 0 to 3 or from 0 to 4. The subject selects a position on this scale that most closely describes their military experience. The numbers corresponding to the positions chosen by the subject are summed up. Higher scores correspond to a greater likelihood that the subject has traumatic experience.

Content (template):

Assessment Form

Full Name_________________________

Date__________________________

INSTRUCTIONS. These questions relate to the nature and duration of your deployment in military operations (if you experienced such), including all events that took place on land, in the air, or at sea. Below each question is a scale ranked from 0 to 3 (or from 0 to 4). Select the position on this scale that most closely describes your military experience, and circle the number corresponding to your choice. Any ambiguities regarding the questions can be clarified with the psychologist conducting your interview.

Key (interpretation)

The total score for each question is calculated. The total score serves as a quantitative measure of combat experience intensity.

Notes for the computer version.

The automatic interpretation of the test score is based on the following percentage-based conditional ratings:

1% - 20% - low level;

21% - 40% - reduced level;

41% - 60% - moderate level;

61% - 80% - elevated level;

81% - 100% - high level.

The questionnaire consists of 7 statements.

Approximate testing time is 5-10 minutes.

Appendix G7 Scale for Assessing the Severity of Psychophysiological Stress Reaction

Russian title: Scale for Assessing the Severity of Psychophysiological Stress Reaction

Original title: Scale for Assessing the Severity of Psychophysiological Stress Reaction

Source: Clinical Psychometrics: Textbook / V. A. Soldatkin, A. I. Kovalev, M. N. Kryuchkova [et al.]; Rostov State Medical University of the Russian Ministry of Health, Department of Psychiatry, Narcology, and Medical Psychology. – Rostov-on-Don: RSMU Publishing House, 2020. – 352 p.

Type (underline):

- rating scale

- index

- questionnaire

- other (please specify):

Purpose:

The Scale for Assessing the Severity of Psychophysiological Stress Reaction is aimed at determining the degree of psychophysiological stress reaction as a predictor of diseases.

Content (template):

Instructions

Mark the number that reflects the frequency of manifestation of a particular symptom in you, and then calculate the total sum.

Key (interpretation):

From 40 to 75 points – minimal likelihood of falling ill due to stress.

From 76 to 100 points – low likelihood of falling ill due to stress.

From 101 to 150 points – high likelihood of falling ill due to stress.

More than 150 points – high likelihood that stress has already affected your health

Appendix G8 Peritraumatic Dissociation Questionnaire

Russian title: Peritraumatic Dissociation Questionnaire

Original title: Peritraumatic Dissociation Questionnaire (Agarkov V. A., Tarabrina N. V., 1998)

Source: Tarabrina N.V. Praktikum po psikhologii posttravmaticheskogo stressa — St. Petersburg: Piter, 2001. — 272 p.,

Type (underline):

- rating scale

- index

- questionnaire

- other (please specify):

Purpose: The Peritraumatic Dissociation Questionnaire (PDQ) was developed in 1998 and includes 9 questions concerning the patient's experiences at the time a potentially traumatic event occurred.

The PDQ is based on a section of the PTSD module [SCID for DSM-III-R (Spitzer R. L. et al., 1990)], the questions of which addressed the subject's experiences at the time a potentially psychotraumatic event was occurring.

Subjects are asked to answer 9 questions describing various dissociative states, such as derealization, depersonalization, out-of-body experiences, etc. Answers are provided on a five-point scale.

The total score is calculated as the arithmetic mean of the 9 items. Diagnostic criteria are as follows: healthy individuals score from 9 to 15 points; patients with post-traumatic stress disorder score from 19 to 45 points.

Content (template):

PERITRAUMATIC DISSOCIATION QUESTIONNAIRE

Date_______________________

Full Name________________________________

INSTRUCTIONS

Please recall as accurately as possible how you felt and what you experienced at the time the most severe of the extraordinary events you experienced took place.

Briefly describe this event

__________________________________________________________________________________________________________________________________________________________

Below are questions about how you felt precisely at that time. Circle the answer option that corresponds to how accurately the description in the question reflects what you felt at the moment of the event.

FORM

Key (interpretation):

The sum of points for each question is calculated. The total score reflects the severity of peritraumatic dissociation.

Appendix G9 Dissociative Experiences Scale (DES)

Russian title: Dissociative Experiences Scale (Agarkov, Tarabrina, 1999).

Original title: Dissociative Experiences Scale — DES (Bernstein E.M., Putnam F.W., 1986)

Source: Tarabrina N.V. Praktikum po psikhologii posttravmaticheskogo stressa — St. Petersburg: Piter, 2001. — 272 p.,

Type (underline):

-rating scale

-index

-questionnaire

-other (specify)

Purpose: The Dissociative Experiences Scale (DES) is a practical testing and research tool designed to identify and assess the severity of dissociative symptoms in psychiatric patients, including those with borderline psychopathological disorders.

The scale is a brief self-report questionnaire consisting of 28 items, in which the respondent is asked to rate how often they experience various dissociative states in daily life. The instructions ask the respondent to rate the frequency of experiencing a particular dissociative phenomenon while not under the influence of psychoactive substances (drugs, alcohol). In cases where the respondent finds it difficult to read for any reason, the researcher or clinician may read the instructions and items aloud and then help the respondent mark the appropriate rating on the form.

The scale yields a single total score calculated across all items.

Content (template):

INSTRUCTIONS.

You are presented with a series of questions about certain situations and experiences from daily life. We are interested in how often these have happened to you. Please remember that your answers should refer only to situations and experiences when you were not under the influence of alcohol or drugs. When answering each question, please determine to what extent the described experience (or situation) has happened to you personally, and circle the number that corresponds to the percentage frequency with which you have experienced this phenomenon or found yourself in such a situation. Circle the number that corresponds to how often this happens to you (as a percentage). If what is stated in the sentence never happens to you, circle 0%; if it always happens to you, circle 100%.

Each statement begins with:

IT HAPPENS THAT SOME PEOPLE (IT HAPPENS TO SOME PEOPLE THAT...)...

If what is stated in this sentence never happens to you, enter "0". If it always happens to you, enter "100". If it happens to you periodically, rate it on a scale from "0" to "100" by selecting the appropriate value.

1) ... while riding the subway, a bus, another form of transportation, or a car, suddenly realize that they do not remember what happened to them during that time or during some part of it.

2) ... while listening to someone, suddenly realize that they did not hear all or part of what was said.

3) ... while in a certain place, cannot remember how they got there.

4) ... find themselves wearing clothes that they cannot remember how or when they put on.

5) ... find something new among their belongings and do not remember how or when they bought it.

6) ... are sometimes approached by strangers who call them by a different name and claim to have met them before.

7) ... experience a feeling as if they are standing next to themselves or observing themselves from the outside like another person.

8) ... are told by others that they sometimes do not recognize friends or family members.

9) ... forget some important events in their lives (e.g., a wedding or graduation).

10) ... have been accused of lying when they felt they were telling the truth.

11) ... looking in the mirror, do not recognize themselves.

12) ... experience a feeling of unreality regarding the people and objects around them, or perhaps the entire world around them.

13) ... feel as though their body does not belong to them.

14) ... sometimes experience an event (or situation) from their past as if it is happening to them again in the present.

15) ... feel doubtful about whether certain events actually occurred in their lives or if they only dreamed them.

16) ... while in a familiar and well-known place, suddenly feel as though they are there for the first time and the place is unfamiliar.

17) ... are so absorbed in a movie or TV show that they no longer notice anything happening around them.

18) ... fantasy or a daydream seems like reality to them.

19) ... sometimes do not notice physical pain.

20) ... sometimes sit staring into space, not thinking about anything and losing track of time.

21) ... when alone, sometimes notice that they are speaking out loud to themselves.

22) ... behave so differently in two similar situations that they feel as though they are two different people.

23) ... sometimes suddenly find it easy to act in situations (e.g., socializing, work, sports, etc.) that usually cause them difficulty.

24) ... sometimes suddenly cannot remember whether they actually did something or only thought about doing it (e.g., do not remember whether they just mailed a letter or only thought about doing so).

25) ... suddenly discover that they have done something and do not remember how it happened.

26) ... sometimes find their own notes, memos, or drawings that they have no memory of making.

27) ... sometimes hear foreign voices inside their heads telling them what to do and commenting on their actions.

28) ... sometimes feel as though they are looking at the world through a fog or haze, making objects and people seem distant or unclear.

Key (interpretation):

The total score of the scale is calculated as the arithmetic mean of the results across all items.

Appendix G10 Beck Hopelessness Scale (BHS)

Russian title: Beck Hopelessness Scale

Original title: Beck Hopelessness Scale, BHS; Beck & Steer, 1988; Beck, Weissman, Lester, & Trexler 1974

Source: Post-traumatic stress disorder / edited by V.A. Soldatkin; SEI HVE RSMU of the Russian Ministry of Health. – Rostov-on-Don: RSMU Publishing House, 2015. – 624 p.

Type (underline):

- rating scale

- index

- questionnaire

- other (please specify):

Purpose: The Beck Hopelessness Scale (BHS) is a scale that measures the severity of negative attitudes toward the subjective future in adults and adolescents. The scale was developed by A. Beck and his colleagues at the Center for Cognitive Therapy of the University of Pennsylvania School of Medicine (USA).

The Beck Hopelessness Scale (BHS) consists of twenty statements. When answering, the respondent expresses agreement or disagreement with each statement according to the given response options: true/false.

The Beck Hopelessness Scale measures the severity of a subject's negative attitude toward their own future. This methodology is of particular value as an indirect indicator of suicide risk in patients suffering from depression, as well as in individuals who have previously made suicide attempts.

Content (template):

Name: Date:

This questionnaire contains 20 statements. Please read each statement carefully. If a statement reflects your mindset over the past week, circle "True" in the column next to the statement. If you disagree with the statement, circle "False".

Scoring and Interpretation

Sum the numbers corresponding to the previously selected answers.

· Key (Interpretation):

· 0-3 Within normal limits (or asymptomatic)

· 4-8 Mild hopelessness

· 9-14 Moderate hopelessness

· 15-20 Severe hopelessness

Appendix G11 Questionnaire for Assessing Therapeutic Dynamics of PTSD

«Treatment Outcome PTSD Scale» (TOP-8)

Russian title: Questionnaire for Assessing Therapeutic Dynamics of PTSD

Original title: Treatment Outcome PTSD Scale (TOP-8)

Source: Post-traumatic stress disorder / ed. by V.A. Soldatkin; Rostov State Medical University of the Russian Ministry of Health. – Rostov-on-Don: Rostov State Med. Univ. Press, 2015. – 624 p.

Type (underline):

- rating scale

- index

- questionnaire

- other (please specify):

Content (template):

Questionnaire for Assessing Therapeutic Dynamics of PTSD (Treatment Outcome PTSD Scale, TOP-8)

Instructions

The interviewer should determine which traumatic event is the most significant, and then assess how much each symptom has bothered the patient over the past week.

1. Have you had distressing images, thoughts, or memories of the trauma that you couldn't get rid of even if you wanted to? Did they occur periodically?

0 – never

1 – Mild: rare and not distressing

2 – Moderate: at least once a week and/or causing mild distress

3 – Severe: at least 4 times a week or causing moderate distress

4 – Very severe: daily, or causing distress to the extent that the patient cannot work or function socially.

2. Does exposure to an event that reminds you of the trauma or is similar to it cause any physical manifestations (e.g., sweating, trembling, palpitations, nausea, rapid breathing, chills, etc.)?

0 – never

1 – A little: rare or questionable

2 – Partly: causing mild distress

3 – Significantly: causing marked distress

4 – Noticeably: causing marked distress or requiring medical attention due to physical symptoms (e.g., chest pain so severe that he/she was convinced they were having a heart attack).

3. Do you persistently avoid places, people, or situations that remind you of the event, such as movies, TV shows, noisy places, veteran gatherings, or funerals?

0 – No avoidance

1 – Mild: of questionable significance (inconvenient, but no avoidance)

2 – Moderate: definitely avoids situations

3 – Severe: very inconvenient, and avoidance interferes with life to some degree

4 – very severe: housebound, unable to go out to shops and restaurants.

4. Do you experience less interest (pleasure) in things that used to bring you joy?

0 – no loss of interest

1 – one or two activities cause less pleasure

2 – several activities cause less pleasure

3 – most activities cause less pleasure

4 – practically all activities cause less pleasure.

5. Do you contact people less than usual? Do you feel alienated from other people?

0 – no problem

1 – mild: feels distant or alienated, but still maintains a normal degree of contact with other people

2 – moderate: sometimes avoids contact that he or she would typically have participated in previously

3 – severe: definitely and usually avoids people with whom he or she previously interacted

4 – very severe: absolutely refuses or actively avoids all social contacts since the trauma.

6. Do you have warm feelings or feel closer to others? Do you feel numb?

0 – no problem

1 – mild: of questionable significance

2 – moderate: some difficulty expressing feelings

3 – severe: definite problems expressing feelings

4 – very severe: has no feelings, feels numb most of the time.

7. Are you on guard? Are you easily distracted? Do you feel like you are on edge?

0 – no problem

1 – mild: periodically / does not interfere

2 – moderate: causes discomfort, feels on edge or vigilant in some situations

3 – severe: causes discomfort, feels on edge or vigilant in most situations

4 – very severe: causes marked discomfort and alters life (constantly on guard, must keep a distance, socially disabled due to the feeling of being on edge).

8. Are you easily startled? Do you have a tendency to startle suddenly? Does this occur after unexpected noise, or if you hear or see something that reminds you of the trauma?

0 – no problem

1 – mild: periodically / does not interfere

2 – moderate: definitely causes discomfort or excessive startle at least once every two weeks

3 – severe: occurs more often than once a week

4 – very severe: so severe that the patient cannot function at work or in society.

Key (interpretation):

The sum of scores for each question is calculated. The quantitative change in the total score reflects the therapeutic dynamics.