What treatment options are available to manage PTSD symptoms at work?

Managing PTSD Symptoms at Work: Treatment and Workplace Accommodation

Approve the FMLA paperwork and initiate trauma-focused psychotherapy immediately, as this represents the evidence-based first-line treatment that will directly address the underlying PTSD symptoms causing workplace distress. 1

Immediate Workplace Accommodation Strategy

The ability to walk away from triggering situations is a reasonable accommodation that aligns with evidence-based anxiety management techniques. 2 Specifically:

• Sensory grounding strategies allow the patient to bring themselves into the present moment when triggered, including noticing environmental details (sounds, sights, smells), feeling textured items, or using cognitive distractors like counting backwards 2
• Diaphragmatic breathing or progressive muscle relaxation can be employed when the patient steps away from triggering situations 2
• These brief interventions (typically 5-10 minutes) allow symptom management without prolonged absence from work duties 2

First-Line Treatment: Trauma-Focused Psychotherapy

Begin trauma-focused psychotherapy immediately without requiring a prolonged stabilization phase, as 40-87% of patients no longer meet PTSD criteria after 9-15 sessions. 1, 3 The three evidence-based options with equivalent efficacy are:

• Prolonged Exposure (PE) 1
• Cognitive Processing Therapy (CPT) 1
• Eye Movement Desensitization and Reprocessing (EMDR) 1

Do not delay treatment by insisting on extended stabilization, as this communicates to the patient that they are incapable of dealing with traumatic memories and reduces motivation for active trauma processing. 4, 3 Emotion dysregulation and workplace distress improve directly with trauma-focused treatment. 4

Telehealth Delivery Option

Trauma-focused psychotherapy can be effectively delivered via secure video teleconferencing, producing similar effect sizes to in-person treatment and improving access for patients who may have difficulty attending in-person sessions due to work schedules. 1, 5

Pharmacotherapy Considerations (If Psychotherapy Insufficient)

If psychotherapy alone is insufficient or the patient strongly prefers medication as an adjunct, first-line pharmacotherapy options include: 1

• Sertraline 50-200 mg daily (FDA-approved for PTSD) 6
• Paroxetine 20-50 mg daily (FDA-approved for PTSD) 7
• Venlafaxine 75-225 mg daily 1

Start sertraline at 50 mg once daily (morning or evening), with dose increases at intervals of at least 1 week based on response. 6 Maintenance treatment typically requires several months or longer of sustained pharmacotherapy. 6

Critical Medications to AVOID

Never prescribe benzodiazepines, as 63% of patients receiving benzodiazepines developed PTSD at 6 months compared to only 23% receiving placebo, and they worsen dissociative symptoms. 4, 1

Expected Treatment Timeline and Outcomes

• Psychotherapy response should be evident within 9-15 sessions 4, 1
• Relapse rates are lower after completing CBT (5-16%) compared to medication discontinuation (26-52%), suggesting psychotherapy provides more durable benefits 1, 3
• If using medication, plan for longer-term treatment as relapse is common after discontinuation 1, 6

Addressing Sleep Disturbance (If Present)

If the patient reports PTSD-related nightmares or sleep disturbance affecting work performance:

• Prazosin is strongly recommended, starting at 1 mg at bedtime, increased by 1-2 mg every few days until effective 3, 8
• Screen for obstructive sleep apnea, as many patients with PTSD-related sleep disturbance have this comorbid condition 8

Monitoring and Follow-Up

• Reassess PTSD symptom severity every 2-4 weeks using standardized measures like the PTSD Checklist for DSM-5 (PCL-5) 8, 9
• Periodically reassess the need for workplace accommodations as symptoms improve with treatment 1
• Screen for psychiatric comorbidities (particularly depression and substance use), which are common and should be treated concurrently 8

Common Pitfalls to Avoid

• Do not label the patient as "too complex" for standard trauma-focused treatment, as this has iatrogenic effects and suggests standard treatments will be ineffective 3
• Do not provide psychological debriefing immediately after new trauma exposure (within 24-72 hours), as this may be harmful 4, 1
• Do not delay trauma processing by focusing exclusively on "stabilization" or coping skills, as affect dysregulation improves directly with trauma-focused treatment 4