What is the treatment algorithm for Post-Traumatic Stress Disorder (PTSD)?

Treatment Algorithm for PTSD

Trauma-focused psychotherapy should be initiated as first-line treatment for PTSD without delay, specifically Prolonged Exposure (PE), Cognitive Processing Therapy (CPT), Eye Movement Desensitization and Reprocessing (EMDR), or Cognitive Therapy (CT), with 40-87% of patients no longer meeting PTSD criteria after 9-15 sessions. 1, 2

First-Line Treatment: Trauma-Focused Psychotherapy

The evidence unequivocally supports trauma-focused psychotherapy over pharmacotherapy as initial treatment. 2, 3, 4

Recommended trauma-focused therapies (choose one):

• Prolonged Exposure (PE) - directly confronts trauma memories through repeated exposure 2, 3
• Cognitive Processing Therapy (CPT) - addresses maladaptive trauma-related beliefs 2, 3
• Eye Movement Desensitization and Reprocessing (EMDR) - processes traumatic memories through bilateral stimulation 2, 3
• Cognitive Therapy (CT) - modifies negative trauma-related appraisals 2, 3

Critical principle: Begin trauma-focused treatment immediately without requiring a prolonged stabilization phase, even in patients with complex presentations including dissociation, emotion dysregulation, or severe symptoms. 1, 5 The assumption that patients need extensive stabilization before trauma processing is not supported by evidence and may delay effective treatment. 6

Treatment duration and monitoring:

• Expect 9-15 sessions for most patients 1
• Treatment response should be evident within this timeframe 5
• Relapse rates are lower after completing psychotherapy compared to medication discontinuation 1

Second-Line Treatment: Pharmacotherapy

Use pharmacotherapy when:

• Psychotherapy is unavailable or inaccessible 1
• Patient strongly prefers medication 1
• Residual symptoms persist after psychotherapy 7
• Patient is unable or unwilling to engage in psychotherapy 7

FDA-Approved Medications

Sertraline (first choice):

• FDA-approved for PTSD 8, 9
• Start 50 mg daily, increase to 50-200 mg/day as needed 8
• Maintenance treatment demonstrated effective for up to 28 weeks following initial 24-week response 8
• Warning: 26-52% relapse rate when discontinued, suggesting need for longer-term treatment 1, 5

Paroxetine (alternative):

• FDA-approved for PTSD 9
• Start 20 mg daily, may increase to 20-50 mg/day 9
• Demonstrated superiority over placebo in multiple 12-week trials 9
• Similar relapse concerns as sertraline upon discontinuation 1

Other Effective Medications (Off-Label)

Venlafaxine:

• Large initial effects demonstrated 4
• Consider when SSRIs inadequate 7

For PTSD-Related Nightmares:

• Prazosin (strongly recommended): Start 1 mg at bedtime, increase by 1-2 mg every few days until effective 10
• Clonidine 0.2-0.6 mg may be considered as alternative 10

Medications to AVOID

Benzodiazepines (including alprazolam):

• Critical warning: 63% of patients receiving benzodiazepines developed PTSD at 6 months versus only 23% receiving placebo 1
• Worsen dissociative symptoms and overall PTSD outcomes 5
• Never use for PTSD treatment 1, 5

Ineffective medications (failed to differentiate from placebo):

• Bupropion, citalopram, divalproex, mirtazapine, tiagabine, topiramate 4
• Aripiprazole, divalproex, guanfacine, olanzapine when combined with antidepressants 4

Complex PTSD Considerations

Do NOT delay trauma-focused treatment for complex presentations. 1, 5

The traditional phase-based approach (stabilization → trauma processing → reintegration) recommended by the 2012 ISTSS guidelines has been critically questioned. 6 Current evidence shows:

• Affect dysregulation and dissociative symptoms improve directly with trauma-focused treatment without requiring prolonged stabilization 1, 5
• Emotion dysregulation stems from trauma-related stimuli and diminishes when trauma memories are addressed 1
• Delaying trauma-focused treatment may communicate to patients they are incapable of dealing with traumatic memories, reducing motivation 5

If stabilization is deemed necessary: Focus on immediate safety concerns only, then proceed rapidly to trauma-focused treatment. 6

Treatment Accessibility

When in-person psychotherapy is unavailable:

• Video or computerized interventions produce similar effect sizes to in-person treatment 1
• These modalities can effectively expand access to evidence-based care 1

Critical Pitfalls to Avoid

Never provide psychological debriefing within 24-72 hours after trauma - this intervention is not supported by evidence and may be harmful. 1, 10, 5

Do not label patients as "too complex" for trauma-focused treatment - this may inadvertently delay access to effective interventions. 10

Monitor for medication discontinuation effects - relapse is common after stopping pharmacotherapy, with significantly lower relapse rates after completing psychotherapy. 1, 5

Assess for obstructive sleep apnea in patients with PTSD-related sleep disturbance, as this condition is common and requires concurrent treatment. 7

Comorbidity Management

Treat psychiatric comorbidities concurrently:

• Mood disorders and substance use are common in PTSD 7
• These conditions should be addressed alongside PTSD treatment, not sequentially 7
• Trauma-focused therapy addresses root causes of emotion dysregulation that fuel comorbid symptoms 1

Maintenance and Long-Term Treatment

Psychotherapy maintenance:

• Periodically reassess need for continued treatment 8
• Most patients achieve durable response after completing acute treatment 1

Pharmacotherapy maintenance:

• If using medication, anticipate need for several months or longer of sustained treatment 8, 9
• Maintain patients on lowest effective dose 8
• Consider longer-term treatment given high relapse rates upon discontinuation 1, 5