What are the diagnostic criteria and treatment options for post-traumatic stress disorder (PTSD)?

Diagnostic Criteria for PTSD

PTSD diagnosis requires exposure to a traumatic event (actual or threatened death, serious injury, or sexual violence) that occurred more than one month ago and causes clinically significant functional impairment, with specific symptom clusters across four domains. 1

Core Diagnostic Requirements

Trauma Exposure (Required)

• The patient must have experienced, witnessed, learned about, or had repeated exposure to details of traumatic events involving actual or threatened death, serious injury, or sexual violence 2, 3, 4
• Symptoms must persist for more than one month after the traumatic event 2, 3, 4
• The disturbance must cause clinically significant impairment in social, occupational, or other important areas of functioning 3, 4

Symptom Cluster 1: Intrusion Symptoms (≥1 Required)

• Recurrent, involuntary, and intrusive distressing memories of the traumatic event 2
• Traumatic nightmares with content related to the event 2
• Dissociative reactions (flashbacks) where the person feels or acts as if the traumatic event is recurring 2
• Intense psychological distress when exposed to internal or external cues that symbolize the traumatic event 3, 4
• Marked physiological reactivity on exposure to trauma-related cues 3, 4

Symptom Cluster 2: Avoidance (≥1 Required)

• Persistent avoidance of trauma-related thoughts, feelings, or internal reminders 2
• Persistent avoidance of external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories 2, 3

Symptom Cluster 3: Negative Alterations in Cognition and Mood (≥2 Required)

• Inability to remember important aspects of the traumatic event (dissociative amnesia, not due to head injury, alcohol, or drugs) 2, 3
• Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world 2
• Persistent distorted cognitions about the cause or consequences of the traumatic event that lead to blaming self or others 2
• Persistent negative emotional state (fear, horror, anger, guilt, shame) 2
• Markedly diminished interest or participation in significant activities 3, 4
• Feelings of detachment or estrangement from others 3, 4
• Persistent inability to experience positive emotions (restricted range of affect) 3, 4
• Sense of foreshortened future 3, 4

Symptom Cluster 4: Alterations in Arousal and Reactivity (≥2 Required)

• Irritable behavior and angry outbursts (with little or no provocation), typically expressed as verbal or physical aggression 2
• Reckless or self-destructive behavior 2
• Hypervigilance 2, 3
• Exaggerated startle response 2, 3
• Problems with concentration 3, 4
• Sleep disturbance (difficulty falling or staying asleep, or restless sleep) 3, 4

Assessment Approach

Initial Screening

• Directly ask patients if anything scary or concerning has happened to them or their family, as most patients with PTSD do not voluntarily report symptoms 2, 5
• Use validated screening tools: the PTSD Reaction Index Brief Form for known trauma exposures or the Pediatric Traumatic Stress Screening Tool in primary care settings 2
• The Clinician-Administered PTSD Scale (CAPS) is the gold standard diagnostic interview, assessing frequency and intensity of symptoms 2
• The PTSD Checklist for DSM-5 uses diagnostic criteria to help diagnose PTSD and determine severity 6

Critical Diagnostic Pitfalls to Avoid

• Do not rely solely on observable behaviors when assessing for PTSD, as most symptoms are internal and require direct questioning 2, 5
• Do not wait for patients to volunteer information about trauma or symptoms—active screening is essential because underdiagnosis is common 2, 5
• Screen children directly when age-appropriate, as parents and teachers may underestimate their distress 2
• Do not overlook partial PTSD, as these patients still benefit from treatment 2

---

Treatment Options for PTSD

First-line treatment for PTSD is trauma-focused psychotherapy (prolonged exposure, cognitive processing therapy, or EMDR), which should be prioritized over pharmacotherapy based on superior efficacy. 1

Evidence-Based Psychotherapy (First-Line Treatment)

Trauma-Focused Cognitive Behavioral Therapies (Strongest Recommendation)

• Prolonged Exposure Therapy: Involves imaginal exposure (repeated recounting of traumatic memory) and in vivo exposure (confrontation with trauma-related situations); 40-87% of patients no longer meet PTSD criteria after 9-15 sessions 1
• Cognitive Processing Therapy: Teaches patients to identify and challenge trauma-related irrational or dysfunctional beliefs; 53-65% of patients achieve remission 1
• Eye Movement Desensitization and Reprocessing (EMDR): Validated trauma-focused therapy with strong evidence for efficacy 1, 7

Other Psychotherapy Options

• Stress Inoculation Training (SIT): Includes education, breathing/relaxation training, cognitive restructuring, and anxiety management techniques; 42-50% remission rates 1
• Cognitive Therapy: Can be effective with or without explicit exposure components; programs including exposure show augmented efficacy 1

Delivery Considerations

• Secure video teleconferencing is recommended to deliver psychotherapy when it has been validated for telehealth use or when in-person options are unavailable 1
• Integrated primary care models with embedded behavioral health providers enhance treatment capacity 5

Pharmacotherapy (Second-Line or Adjunctive Treatment)

FDA-Approved First-Line Medications

• Sertraline: FDA-approved for PTSD; 53-85% of patients classified as treatment responders in clinical trials 1, 3
• Paroxetine: FDA-approved for PTSD; demonstrated superiority over placebo on CAPS-2 scores and CGI-I responder rates 1, 4
• Venlafaxine (SNRI): Recommended alongside SSRIs as first-line pharmacotherapy 1

Other Effective SSRIs (Not FDA-Approved for PTSD but Evidence-Based)

• Fluoxetine: Shown to be more effective than placebo in PTSD treatment since 1994 1

Medications for Specific Symptoms

• Prazosin: Effective for PTSD-related nightmares and sleep disturbance 2, 6
• Atypical antipsychotics or topiramate: May be helpful for residual symptoms after first-line treatment 6

Medications to AVOID (Strong Recommendation Against)

• Benzodiazepines: The VA/DoD guideline recommends against their use in PTSD 1
• Cannabis or cannabis-derived products: Strong recommendation against use 1

Treatment Algorithm

Step 1: Initial Management

• Offer trauma-focused psychotherapy as first-line treatment (prolonged exposure, cognitive processing therapy, or EMDR) 1, 7
• Reserve pharmacotherapy for patients with residual symptoms after psychotherapy or those unable/unwilling to access psychotherapy 6

Step 2: Pharmacotherapy When Indicated

• Start with sertraline, paroxetine, or venlafaxine as first-line agents 1
• Consider adding atypical antipsychotics or topiramate for residual symptoms 6

Step 3: Address Comorbidities and Sleep

• Screen for obstructive sleep apnea in patients with PTSD-related sleep disturbance, as many have this condition 2, 6
• Use prazosin for nightmare-related sleep problems 2, 6
• Treat comorbid depression, anxiety disorders, and substance use concurrently, as these are extremely common (41% have secondary major depression; 40% have non-PTSD anxiety disorders) 2, 4, 6

Step 4: Complex PTSD Considerations

• For complex PTSD with severe emotion dysregulation, consider phase-based treatment with initial stabilization focusing on emotion regulation before trauma processing 1, 2
• However, evidence increasingly supports trauma-focused therapy even in vulnerable populations without mandatory stabilization phases 1

Treatment Duration and Monitoring

• PTSD symptoms can persist or fluctuate over time, requiring ongoing monitoring 2
• Trauma triggers may cause symptom recurrence even after successful treatment 2
• Periodically re-evaluate the long-term usefulness of pharmacotherapy for individual patients 3, 4