What management approach is recommended for a 15-year-old female patient with post-traumatic stress disorder (PTSD), experiencing racing thoughts and insomnia, following the sudden death of a relative a couple of months ago, until she can see her primary provider or mental health specialist?

Immediate Management for Adolescent PTSD with Insomnia and Racing Thoughts

Focus on sleep stabilization and supportive care while expediting mental health referral—avoid starting SSRIs yourself in this single visit, as trauma-focused psychotherapy is first-line treatment and should be coordinated by her ongoing providers. 1, 2

Immediate Actions for Tomorrow's Visit

Address Sleep Disturbance First

• Teach Progressive Deep Muscle Relaxation (PDMR) during the visit as this can reduce nightmare frequency by 80% and provides immediate coping skills the patient can use that night. 3
• Provide written instructions for PDMR: tensing and releasing muscle groups systematically, one body part at a time, to induce physical relaxation and reduce anxiety. 3
• This intervention has Level B evidence and works for both PTSD-associated and idiopathic nightmares. 3

Sleep Hygiene Education

• Review basic sleep hygiene principles as part of cognitive-behavioral approach to insomnia in PTSD. 3, 1
• Emphasize consistent sleep-wake times, avoiding screens before bed, and creating a calm bedtime routine. 3

Assess for Nightmare Disorder

• Ask specifically about nightmares versus general insomnia—up to 80% of PTSD patients report nightmares, which predict PTSD severity and require targeted intervention. 3
• If nightmares are prominent, introduce the concept of Image Rehearsal Therapy (IRT) which has Level A evidence: patient recalls the nightmare, writes it down, changes the ending to something positive, and rehearses the new version for 10-20 minutes daily while awake. 3

What NOT to Do in This Single Visit

Avoid Initiating Pharmacotherapy Yourself

• Do not start SSRIs (fluoxetine, paroxetine, sertraline) or SNRIs (venlafaxine) in this single encounter—while these are first-line pharmacologic treatments for PTSD, they work best alongside psychotherapy and require ongoing monitoring you cannot provide. 1, 2
• SSRIs treat primary PTSD symptoms but psychotherapy remains first-line treatment, particularly trauma-focused cognitive behavioral therapy. 1, 2

Avoid Alpha-2 Agonists for Daytime Symptoms

• Do not prescribe clonidine or guanfacine for racing thoughts—these cause somnolence and sedation as their most common adverse effects, making them unsuitable for daytime hyperarousal. 4
• These medications are dosed in the evening specifically because of sedation risk. 4

Coordinate Urgent Follow-Up

Expedite Mental Health Referral

• Contact her primary provider today to communicate the severity and request urgent mental health appointment within 1-2 weeks maximum. 1
• Document that patient has PTSD symptoms in all four domains: intrusive thoughts (racing thoughts about the death), avoidance behaviors, negative mood alterations, and increased arousal (insomnia). 1, 5

Screen for Comorbidities

• Assess for depression—80% of PTSD patients have at least one comorbid psychiatric disorder, most commonly depression. 6, 7
• Ask about substance use, as alcohol/drug abuse commonly co-occurs with PTSD. 6, 7
• Screen for suicidal ideation given recent traumatic loss and sleep deprivation. 1

Safety Planning

• Provide crisis resources: National Suicide Prevention Lifeline (988), Crisis Text Line (text HOME to 741741). 1
• Ensure patient has support system and is not isolated. 3
• Schedule follow-up with her primary provider within 3-5 days if mental health appointment cannot be secured immediately. 1

Key Pitfall to Avoid

The biggest mistake would be starting an SSRI without coordinating with her ongoing providers and without ensuring trauma-focused psychotherapy is arranged—medications are adjunctive to psychotherapy in PTSD, not standalone treatment. 1, 2 Your role in this single visit is crisis stabilization and care coordination, not initiating long-term pharmacotherapy.