What is the initial treatment approach for a patient with post-traumatic stress disorder (PTSD)?

Treatment Algorithm for PTSD

First-Line Treatment: Trauma-Focused Psychotherapy

Initiate trauma-focused psychotherapy immediately as first-line treatment without requiring a prolonged stabilization phase, even in patients with complex presentations, dissociation, or emotion dysregulation. 1, 2

The 2023 VA/DoD Clinical Practice Guideline strongly recommends three specific manualized trauma-focused psychotherapies with the strongest evidence base: 1

• Prolonged Exposure (PE) - 40-87% of patients no longer meet PTSD criteria after 9-15 sessions 1, 3
• Cognitive Processing Therapy (CPT) - equally effective as exposure-based approaches 1, 3
• Cognitive Therapy (CT) - addresses negative trauma-related appraisals that fuel emotion dysregulation 1, 2
• Eye Movement Desensitization and Reprocessing (EMDR) - demonstrates clinically important effects comparable to CBT-based approaches 1, 3, 4

These therapies can be delivered individually (preferred) or via secure video teleconferencing when in-person options are unavailable. 1

Second-Line Treatment: Pharmacotherapy

Use pharmacotherapy when psychotherapy is unavailable, ineffective, the patient refuses psychotherapy, or residual symptoms persist after psychotherapy. 1, 5

First-Line Medications (in alphabetical order):

• Paroxetine - 20-40 mg/day; demonstrated significantly superior to placebo on CAPS-2 total score and CGI-I responder rates; no additional benefit for doses higher than 20 mg/day 1, 6, 7
• Sertraline - 50-200 mg/day; effective for PTSD with mean dose of 70 mg/day in maintenance studies 1, 8, 5
• Venlafaxine - serotonin-norepinephrine reuptake inhibitor with consistent positive results 1, 5, 7

Medication Duration:

• Continue SSRI treatment for 6-12 months minimum after symptom remission 1
• Relapse rates are 26-52% when shifted to placebo versus only 5-16% maintained on medication 1
• Relapse rates are significantly lower after completing psychotherapy compared to medication discontinuation 1, 2

Adjunctive Treatment for Specific Symptoms

PTSD-Related Nightmares and Sleep Disturbance:

• Prazosin - Level A evidence for PTSD-related nightmares 1, 5
• Initial dose: 1 mg at bedtime, increase 1-2 mg every few days 1
• Average effective dose: 3 mg (range 1-13 mg) 1
• Monitor for orthostatic hypotension 1

Critical Medications to AVOID

Never prescribe benzodiazepines for PTSD treatment - 63% of patients receiving benzodiazepines developed PTSD at 6 months compared to only 23% receiving placebo. 1, 9, 5

The 2023 VA/DoD guideline strongly recommends AGAINST benzodiazepines, as they worsen PTSD outcomes and may be harmful. 1

Treatment Algorithm Decision Tree

Step 1: Initial Assessment

• Diagnose PTSD using DSM-5 criteria and PTSD Checklist for DSM-5 5
• Screen for psychiatric comorbidities (mood disorders, substance use) - treat concurrently, not sequentially 2, 5
• Assess for acute suicidality, active substance dependence requiring detoxification, or current psychotic symptoms requiring stabilization 2

Step 2: Offer Trauma-Focused Psychotherapy

• If patient accepts: Initiate PE, CPT, CT, or EMDR immediately (9-15 sessions) 1, 3
• If psychotherapy unavailable or patient refuses: Proceed to Step 3 1

Step 3: Pharmacotherapy

• Start paroxetine 20 mg/day OR sertraline 50 mg/day 1, 6, 8
• Titrate based on response; continue 6-12 months after remission 1

Step 4: Address Residual Symptoms

• For persistent nightmares: Add prazosin 1, 5
• For residual symptoms after psychotherapy: Add SSRI as adjunct 1, 2
• For inadequate response to monotherapy: Consider atypical antipsychotics or topiramate for augmentation 5

Common Pitfalls to Avoid

• Do not delay trauma-focused treatment by requiring prolonged stabilization phases - this lacks empirical support and may communicate to patients they are incapable of processing traumatic memories 9, 2
• Do not use psychological debriefing within 24-72 hours post-trauma - randomized controlled trials show it may be harmful 1, 9
• Do not assume complex PTSD requires different treatment - emotion dysregulation and dissociative symptoms improve directly with trauma-focused treatment without requiring separate stabilization interventions 9, 2
• Do not use beta blockers as monotherapy for established PTSD - they have only been studied for prevention immediately post-trauma, not chronic PTSD treatment 1

Special Populations

Complex PTSD with Dissociation:

• Initiate trauma-focused psychotherapy immediately without prolonged stabilization 9, 2
• Dissociative symptoms are intrusive PTSD symptoms that improve with trauma processing, not separate pathology requiring distinct treatment 9

Pediatric Patients (ages 6-17):

• Sertraline: 25 mg/day for children ages 6-12; 50 mg/day for adolescents ages 13-17 8
• Maximum dose: 200 mg/day; adjust for lower body weights 8