PTSD Assessment and Treatment Plan
For PTSD, initiate trauma-focused psychotherapy (cognitive processing therapy, prolonged exposure, or EMDR) as first-line treatment without delay, and use SSRIs (paroxetine, sertraline) or venlafaxine as pharmacotherapy when psychotherapy is unavailable or as adjunctive treatment. 1
Assessment Protocol
Diagnostic Evaluation
- Use the PTSD Checklist for DSM-5 (PCL-5) to screen and assess symptom severity, which directly maps to DSM-5 diagnostic criteria 2
- Administer the Clinician-Administered PTSD Scale (CAPS) for definitive diagnosis and severity assessment, as it demonstrates excellent reliability and validity across items, raters, and testing occasions 3
- Assess for the three core symptom clusters: trauma-related intrusive thoughts, avoidant behaviors, negative alterations of cognition or mood, and changes in arousal and reactivity 2
Critical Assessment Components
- Screen for trauma history in all patients presenting with anxiety or psychiatric symptoms, as this aids in accurate diagnosis 2
- Evaluate for psychiatric comorbidities, particularly mood disorders and substance use disorders, which are common and require concurrent treatment 2
- Test for obstructive sleep apnea in patients with PTSD-related sleep disturbance, as many have this condition 2
- Assess peritraumatic response and cognitions, as these confer the greatest risk for PTSD development 4
Treatment Algorithm
First-Line: Trauma-Focused Psychotherapy
Offer trauma-focused psychotherapy immediately without mandatory stabilization phases, even in complex presentations 1, 5, 6
Choose from these evidence-based options (all equally effective):
- Cognitive Processing Therapy 1
- Prolonged Exposure Therapy 1, 4
- Eye Movement Desensitization and Reprocessing (EMDR) 1
Expected outcomes: 40-87% of patients no longer meet PTSD criteria after 9-15 sessions 7
Pharmacotherapy Indications
Initiate medication when:
- Psychotherapy is unavailable or inaccessible 7, 2
- Patient strongly prefers medication 1, 7
- Residual symptoms persist after psychotherapy 2
First-line medications:
For PTSD-related nightmares specifically:
Adjunctive Treatment for Residual Symptoms
- Consider atypical antipsychotics or topiramate for persistent symptoms despite first-line treatment 2
Critical Pitfalls to Avoid
Do NOT Use These Interventions
- Avoid benzodiazepines entirely: 63% of patients receiving benzodiazepines developed PTSD at 6 months versus only 23% receiving placebo 7, 1
- Do not recommend cannabis or cannabis-derived products 1
- Never provide psychological debriefing within 24-72 hours after trauma, as this may be harmful 7, 6
Do NOT Delay Treatment
- Do not insist on prolonged stabilization phases before trauma-focused therapy, as this communicates incapability and reduces motivation for trauma processing 5, 7
- Avoid labeling patients as "complex", as this has iatrogenic effects by suggesting standard treatments will be ineffective 5, 6
- Do not assume affect dysregulation or dissociative symptoms require extensive pre-treatment stabilization—these symptoms improve with trauma-focused treatment 5
Treatment Delivery Considerations
Telehealth Options
- Use secure video teleconferencing to deliver recommended psychotherapy when validated for this modality or when in-person options are unavailable 1
- Video or computerized interventions produce similar effect sizes to in-person treatment and improve access 7
Monitoring and Follow-Up
- Anticipate relapse after medication discontinuation: 26-52% of patients relapse when shifted from sertraline to placebo versus only 5-16% maintained on medication 7, 1
- Relapse rates are lower after CBT completion compared to medication discontinuation, suggesting psychotherapy provides more durable benefits 7
- Consider longer-term medication treatment given high relapse rates after discontinuation 7