Bernstein, Dr. David M.

Bracha, Dr. Stefan

Ralston, Tyler

Williams, Andrew E.

English

Cognitive Sciences ePrint Archive

40 V O L .  4 ,  N O .  4  /  A P R I L  2 0 0 5
osttraumatic stress disorder (PTSD) is
underdiagnosed among combat-exposed
individuals and overdiagnosed among
civilians. An expanded, nondichotomous check-
list of emotional and physical signs following a
disaster may help address this problem.
P TSD diagnostic criteria shortcomings 
Schnurr et al calculated that DSM-IV-TR diag-
nostic criteria A1 and A2 for PTSD together have
a 34% positive predictive value when applied to
victims of violent crime.1 Many who meet these
criteria may not need intervention, and some
interventions—such as critical incident stress
debriefing—may be detrimental.2,3
DSM-IV criteria A1 and A2 do not take into
account common peritraumatic autonomic activa-
tion signs—shortness of breath, tremulousness, rac-
ing heart, and sweaty palms/cold sweat—that are
part of the human hardwired acute response to
H. Stefan Bracha, MD, Andrew E. Williams, MA, 
Tyler C. Ralston, MA, and David M. Bernstein, MD  
Preventing post-disaster PTSD: Watch for autonomic signs
earlsP
P
Dr. Bracha is research psychiatrist, National
Center for Posttraumatic Stress Disorder,
Department of Veterans Affairs, Pacific Islands
Health Care System, Spark M. Matsunaga Medical
Center, Honolulu, HI; and is associate professor,
affiliate graduate faculty, psychology department,
University of Hawaii at Manoa, Honolulu.
Mr. Williams is a psychology graduate student,
University of Hawaii at Manoa.
Mr. Ralston is a psychology graduate student,
Argosy University, Honolulu. 
Dr. Bernstein is associate chief of staff, Mental
Health Services, Department of Veterans Affairs,
Pacific Islands Health Care System, Spark M.
Matsunaga Medical Center.
p S Y CH I AT R Y
Current
Current
p S Y CH I A T R Y
threat.4 Last year we published a research check-
list of criteria A1 and A2 symptoms plus the four
autonomic signs, which we collectively refer to as
“criterion A3.”4
A preliminary (tentatively weighted) clinical
version of this checklist, the PTSD Criterion A3
Checklist (Table, page 43), may be useful for screen-
ing persons in the acute aftermath of a disaster.
While more research is needed, this version is:
Fear-specific. The checklist includes queries
about two peritraumatic, fear-specific signs
(tremulousness and sweaty palms/cold sweat) as
well as peritraumatic tachycardia and dyspnea. 
Brief. This tool takes as little as 2 minutes to
administer, thus minimizing the burden on vic-
tims in the days or weeks after a mass disaster. 
Non-dichotomous but easy to score. One point is
scored for each “Yes” answer for 8 of the 10
queries; “Yes” answers to the two other queries
are worth 4 and 3 points, respectively. A total
score of 5 or more may indicate a need for pre-
ventive intervention such as propranolol, 40 mg
tid or qid for 7 to 10 days.5,6
Minimizes stigma. Assessing peritraumatic physi-
cal signs may help minimize stigma-related bias.4
This is important when screening persons likely
to underreport criterion A2 symptoms, including: 
• veterans 
• military personnel
• firefighters 
• police officers
• men in general 
• persons from ethnic cultures in which having
psychiatric symptoms is viewed as disgraceful. 
Easy to remember. After a few administrations, the
queries can be easily memorized and incorporat-
cont inued on page 43
                                                     
43V O L .  4 ,  N O .  4  /  A P R I L  2 0 0 5
PTSD Criterion A3 Checklist
Table
Incident: Total score*
(0-15):
Time since incident: ________________
At the time, did you… Points for 
“Yes” answers   
Think… That you would be seriously physically 4 Total 
injured or killed? A1 score:
Criterion A1 That a close family member would be  3
seriously physically injured or killed?
That someone else would be killed?  1
Feel… Intense fear or fright? 1 Total 
Criterion A2 Helpless? 1 A2 score:
Horrified? 1
Experience… Shortness of breath? 1 Total 
Criterion A3 Trembling, shaking or buckling knees? 1 A3 score:
(Proposed for DSM-V) Racing/pounding heart? 1
Sweaty palms or other cold sweat? 1
• Consider preventive intervention (eg, propranolol regimen) if total score is 5 or more.
p S Y CH I AT R Y
Current
ed into initial assessments. The four acute auto-
nomic activation signs can be remembered with
the acronym “STRS” (shortness of breath, trem-
bling, racing heart, sweaty palms). Consider “A3”
a mnemonic for “acute autonomic activation.”
References
1. Schnurr PP, Spiro A, Vielhauer MJ, et al. Trauma in the lives of
older men: findings from the normative aging study. J Clin
Geropsychol 2003;8:175-87.
2. Wessely S, Rose S, Bisson J. Brief psychological interventions
("debriefing") for trauma-related symptoms and the prevention of
post traumatic stress disorder. Cochrane Database Syst Rev
2000;CD000560. 
3. Bisson JI, Jenkins PL, Alexander J, Bannister C. Randomised con-
trolled trial of psychological debriefing for victims of acute burn
trauma. Br J Psychiatry 1997;171:78-81. 
4. Bracha HS, Williams AE, Haynes SN, et al. The STRS (shortness
of breath, tremulousness, racing heart, and sweating): A brief check-
list for acute distress with panic-like sympathetic indicators; develop-
ment and factor structure. Ann Gen Hosp Psychiatry 2004;3:1-11.
Available at: http://www.annals-general-psychiatry.com/content/pdf/
1475-2832-3-8.pdf
5. Pitman RK, Sanders KM, Zusman RM, et al. Pilot study of sec-
ondary prevention of posttraumatic stress disorder with propra-
nolol. Biol Psychiatry 2002;51:189-92.
6. Vaiva G, Ducrocq F, Jezequel K, et al. Immediate treatment with
propranolol decreases posttraumatic stress disorder two months
after trauma. Biol Psychiatry 2003;54:947-9.
ACKNOWLEDGMENT
This material is based on work supported in part by the Office of
Research and Development, Medical Research Service, Department of
Veterans Affairs, VA Pacific Islands Health Care System, Spark M.
Matsunaga Medical Center. Support was also provided by a National
Alliance for Research on Schizophrenia and Depression Independent
Investigator Award to Dr. Bracha and the VA National Center for
Posttraumatic Stress Disorders.
cont inued f rom page 40
earlsP
                                             


Brief psychological interventions (&quot;debriefing&quot;) for trauma-related symptoms and the prevention of post traumatic stress disorder. Cochrane Database Syst Rev

Pilot study of secondary prevention of posttraumatic stress disorder with propranolol.

Randomised controlled trial of psychological debriefing for victims of acute burn trauma.

The STRS (shortness of breath, tremulousness, racing heart, and sweating): A brief checklist for acute distress with panic-like sympathetic indicators; development and factor structure. Ann Gen Hosp Psychiatry 2004;3:1-11. Available at:

Trauma in the lives of older men: findings from the normative aging study.

Preventing post-disaster PTSD: Watch for autonomic signs

Preventing post-disaster PTSD: Watch for autonomic signs

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