What treatment options are available for anxiety and potential post-traumatic stress disorder (PTSD) symptoms after experiencing mental and physical abuse from a relative?

Treatment for Anxiety and PTSD Following Mental and Physical Abuse

You should begin trauma-focused cognitive behavioral therapy (TFCBT) with exposure therapy as first-line treatment, which shows 40-87% of patients no longer meeting PTSD criteria after 9-15 sessions, and if psychotherapy is unavailable or declined, start an SSRI such as sertraline 50 mg daily. 1, 2

Immediate Treatment Priorities

First-Line: Trauma-Focused Psychotherapy

• Trauma-focused CBT with exposure therapy is the most effective treatment, demonstrating superior outcomes to all other interventions for both PTSD and anxiety symptoms following abuse 1, 2
• The exposure component involves repeated recounting of traumatic memories (imaginal exposure) and confronting trauma-related situations that trigger anxiety (in vivo exposure) 1
• Alternative evidence-based psychotherapies include Eye Movement Desensitization and Reprocessing (EMDR), cognitive therapy, or stress inoculation training if exposure therapy is not tolerated 1, 2
• Treatment typically requires 9-15 sessions, with benefits maintained at 3-6 month follow-ups 1

Pharmacotherapy When Psychotherapy is Unavailable or Insufficient

• Sertraline is FDA-approved for PTSD and should be started at 50 mg once daily, either morning or evening 3
• Other SSRIs (fluoxetine, paroxetine) or the SNRI venlafaxine are equally effective alternatives 1, 4
• Dose increases of 50 mg increments can be made at intervals of at least 1 week if insufficient response, up to 200 mg/day 3
• Continue medication for at least 9-12 months after symptom improvement to prevent relapse, as 26-52% of patients relapse when medication is discontinued prematurely 2, 3

Addressing Sleep Difficulties

• Avoid benzodiazepines entirely—evidence shows 63% of patients receiving benzodiazepines developed PTSD at 6 months compared to only 23% receiving placebo 1, 2
• Consider prazosin specifically for PTSD-related nightmares and sleep disturbance 4
• Screen for obstructive sleep apnea, which is common in PTSD-related sleep disturbance 4
• Cognitive behavioral therapy for insomnia (CBT-I) is preferred over medication for sleep problems 5

Critical Interventions to Avoid

• Do not use psychological debriefing immediately after trauma—this intervention may be harmful and worsen outcomes 1, 2, 6
• Discontinue any benzodiazepines (alprazolam, clonazepam) as they significantly worsen PTSD outcomes 1, 2
• Avoid tricyclic antidepressants as first-line treatment due to lack of efficacy and higher overdose risk 7

Treatment Algorithm for Your Situation

Step 1: Immediate referral for trauma-focused CBT 2, 6

• Schedule 9-15 sessions focusing on the abuse trauma
• If unavailable in your area, video-based or computerized interventions produce similar outcomes to in-person treatment 2

Step 2: If psychotherapy is declined, unavailable, or provides insufficient response 2

• Start sertraline 50 mg daily 3, 4
• Increase by 50 mg every 1-2 weeks if needed, up to 200 mg/day 3
• Monitor for 4-6 weeks before assessing full response 8

Step 3: Address sleep disturbance 4

• Add prazosin for nightmares if present
• Refer for CBT-I if insomnia persists
• Screen for sleep apnea

Step 4: Continuation treatment 2, 3

• Continue effective treatment for 9-12 months minimum after symptom remission
• Relapse rates are significantly lower after completing CBT compared to medication discontinuation 2

Evidence Quality Considerations

The strongest evidence supports trauma-focused psychotherapy over medication, with multiple well-conducted randomized controlled trials showing 40-87% remission rates 1. SSRIs have consistent positive results in placebo-controlled trials with 53-85% classified as treatment responders, though relapse is common after discontinuation 1. Psychological First Aid (PFA) showed superior anxiety reduction in four trials, though effects on PTSD symptoms were more variable 1.

Common Pitfalls

• Starting with medication alone when psychotherapy is available—psychotherapy provides more durable benefits 2
• Using benzodiazepines for anxiety or sleep, which paradoxically worsens PTSD outcomes 1, 2
• Discontinuing treatment too early—maintain for at least 9-12 months after response 2, 3
• Failing to address comorbid depression, which is present in the majority of PTSD cases 9, 4