What are the diagnostic criteria and treatment options for Post-Traumatic Stress Disorder (PTSD)?

Diagnostic Criteria and Treatment Options for Post-Traumatic Stress Disorder (PTSD)

Post-Traumatic Stress Disorder (PTSD) requires a comprehensive diagnostic assessment based on DSM-5 criteria, with first-line treatment being trauma-focused psychotherapy such as EMDR or trauma-focused CBT, followed by SSRIs like sertraline or paroxetine when necessary. 1, 2

Diagnostic Criteria

PTSD diagnosis requires the following criteria to be present for more than one month and cause significant impairment in functioning:

1. Exposure to Trauma

   • Direct experience of traumatic event
   • Witnessing trauma happening to others
   • Learning about trauma occurring to close family/friend
   • Repeated exposure to details of traumatic events 1

2. Intrusion Symptoms (at least one required)

   • Recurrent, intrusive, distressing memories
   • Traumatic nightmares
   • Flashbacks (dissociative reactions)
   • Intense psychological distress at exposure to trauma cues
   • Physiological reactions to trauma reminders 1

3. Avoidance (at least one required)

   • Avoiding trauma-related thoughts or feelings
   • Avoiding trauma-related external reminders (people, places, activities) 1

4. Negative Alterations in Cognition and Mood (at least two required)

   • Inability to remember important aspects of the trauma
   • Persistent negative beliefs about oneself, others, or the world
   • Distorted thoughts about cause/consequences leading to self/other blame
   • Persistent negative emotional state
   • Diminished interest in significant activities
   • Feelings of detachment from others
   • Persistent inability to experience positive emotions 1

5. Alterations in Arousal and Reactivity (at least two required)

   • Irritable behavior and angry outbursts
   • Reckless or self-destructive behavior
   • Hypervigilance
   • Exaggerated startle response
   • Problems with concentration
   • Sleep disturbance 1

Assessment Tools

• PTSD Checklist for DSM-5 (PCL-5): Standardized self-report measure that corresponds to DSM-5 criteria 2
• Clinician-Administered PTSD Scale (CAPS): Gold standard diagnostic interview for PTSD, assessing frequency and intensity of 17 symptoms 1

Treatment Options

First-Line Treatments

1. Psychotherapy

   • Eye Movement Desensitization and Reprocessing (EMDR): Most effective at reducing symptoms (SMD -2.07) and improving remission rates 3
   • Trauma-Focused Cognitive Behavioral Therapy (TF-CBT): Highly effective (SMD -1.46) with sustained effects at 1-4 month follow-up 3
   • Combined Somatic/Cognitive Therapies: Effective for symptom reduction (SMD -1.69) 3
   • Self-Help with Support: Effective for both symptom reduction and improving remission rates 3

2. Pharmacotherapy (when psychotherapy is unavailable, ineffective, or patient preference)

   • Selective Serotonin Reuptake Inhibitors (SSRIs):
     • Sertraline: FDA-approved for PTSD treatment 4
     • Paroxetine: FDA-approved for PTSD treatment 5
     • Fluoxetine: Effective for primary PTSD symptoms 2
   • Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs):
     • Venlafaxine: Effective for primary PTSD symptoms 2

Second-Line/Adjunctive Treatments

• Prazosin: Effective specifically for PTSD-related nightmares and sleep disturbance 2
• Atypical Antipsychotics: May help with residual symptoms when added to first-line treatments 2
• Topiramate: May be helpful for residual symptoms 2

Special Considerations

• Sleep Disturbances: Common in PTSD and may require specific treatment

  • Screen for obstructive sleep apnea, which is common in PTSD patients with sleep disturbance 2
  • Consider prazosin specifically for nightmare-related sleep problems 1, 2

• Comorbidities: Extremely common and require concurrent treatment

  • Depression and other anxiety disorders frequently co-occur with PTSD 1, 2, 6
  • Substance use disorders are common and should be addressed simultaneously 2, 6

• Complex PTSD: Some patients may present with more severe, complex symptoms

  • May require phase-based treatment with initial stabilization focusing on emotion regulation before trauma processing 1
  • However, evidence for requiring a stabilization phase before trauma-focused therapy is limited 1

Treatment Duration and Follow-up

• For pharmacotherapy, periodic re-evaluation of long-term usefulness is recommended 4, 5
• PTSD symptoms can persist or fluctuate over time, requiring ongoing monitoring 1
• Trauma triggers may cause symptom recurrence even after successful treatment 1

Common Pitfalls to Avoid

• Underdiagnosis: Many patients with PTSD do not voluntarily report symptoms and require direct screening 1
• Focusing only on overt behaviors: Parents/caregivers tend to underestimate distress in children with PTSD 1
• Overlooking partial PTSD: Patients with PTSD-related symptoms who don't meet full diagnostic criteria still benefit from treatment 1
• Neglecting comorbidities: Failing to address concurrent depression, anxiety, or substance use disorders 2, 6