Assessment and Treatment of PTSD
Assessment
Screen all patients with anxiety or psychiatric symptoms for past trauma exposure, as PTSD is commonly underdiagnosed due to patient minimization, clinician oversight, or failure to obtain a trauma history. 1, 2
Diagnostic Criteria and Tools
Use the PTSD Checklist for DSM-5 (PCL-5) to diagnose PTSD and determine symptom severity, which directly applies DSM-5 diagnostic criteria. 1
Confirm the presence of three core symptom clusters: (1) trauma-related intrusive thoughts, (2) avoidant behaviors, and (3) negative alterations in cognition/mood with changes in arousal and reactivity. 1
Symptoms must persist for at least one month after a traumatic event involving threat of death or serious physical harm; earlier symptoms represent acute stress disorder, not PTSD. 1
Critical Assessment Components
Obtain a detailed trauma history, including type, chronicity, and developmental timing of trauma exposure. 2, 3
Screen for psychiatric comorbidities, particularly major depression, substance use disorders, and other anxiety disorders, which occur in the majority of PTSD patients and require concurrent treatment. 1, 4
Assess sleep disturbance patterns and consider testing for obstructive sleep apnea, as many patients with PTSD-related sleep disturbance have undiagnosed sleep apnea. 1
Treatment Algorithm
First-Line: Trauma-Focused Psychotherapy
Initiate trauma-focused psychotherapy immediately without requiring a prolonged stabilization phase, even in patients with complex presentations including dissociation, emotion dysregulation, or severe comorbidities. 5, 6
Offer Prolonged Exposure (PE), Cognitive Processing Therapy (CPT), Eye Movement Desensitization and Reprocessing (EMDR), or Cognitive Therapy (CT) as first-line interventions. 5, 7
These therapies achieve remission in 40-87% of patients after 9-15 sessions, with significantly lower relapse rates compared to medication discontinuation. 5, 8
Do not delay trauma-focused treatment by labeling patients as "too complex" or requiring extensive stabilization first—this assumption lacks empirical support and may inadvertently harm patients by restricting access to effective treatment. 5, 6
Critical Paradigm Shift
The traditional phase-based approach recommending prolonged stabilization before trauma processing is not supported by current evidence. 5
No randomized controlled trials demonstrate that patients with complex PTSD require or benefit from prolonged stabilization before trauma processing. 5
Emotion dysregulation and dissociative symptoms improve directly through trauma processing itself, without requiring separate stabilization interventions. 5, 7
Delaying trauma-focused treatment may communicate to patients that they are incapable of processing traumatic memories, reducing self-confidence and motivation. 5
Second-Line: Pharmacotherapy
Use pharmacotherapy when psychotherapy is unavailable, ineffective, strongly preferred by the patient, or when residual symptoms persist after psychotherapy. 5, 6
First-Line Medications
Selective serotonin reuptake inhibitors (SSRIs): sertraline, paroxetine, or fluoxetine have the strongest evidence base. 1, 8, 4
Venlafaxine (serotonin-norepinephrine reuptake inhibitor) is equally effective. 7, 1
Continue treatment for 6-12 months minimum after symptom remission before considering discontinuation. 7
Adjunctive Medications
Prazosin specifically for PTSD-related nightmares: start 1 mg at bedtime, increase by 1-2 mg every few days, average effective dose 3 mg (range 1-13 mg), monitor for orthostatic hypotension. 7, 1
Atypical antipsychotics or topiramate may help with residual symptoms. 1
Critical Medication Warnings
Avoid benzodiazepines entirely in PTSD treatment—evidence shows 63% of patients receiving benzodiazepines developed PTSD at 6 months compared to only 23% receiving placebo. 7, 6
- Benzodiazepines worsen PTSD outcomes and should never be used for this indication. 7
Do not use psychological debriefing (single-session intervention within 24-72 hours post-trauma)—randomized controlled trials show no benefit and potential harm. 7, 6
Relapse Prevention
Relapse rates after medication discontinuation are 26-52% compared to only 5-16% maintained on medication. 5, 8
Relapse rates after completing trauma-focused psychotherapy are significantly lower (5-16%) than after medication discontinuation, demonstrating more durable benefits. 5, 8
Treatment of Complex PTSD
The distinction between PTSD and complex PTSD is increasingly unclear, as symptoms previously considered unique to complex PTSD (emotion dysregulation, dissociation, interpersonal problems) are now recognized as common in standard PTSD and incorporated into DSM-5 criteria. 9, 5
Offer the same evidence-based trauma-focused therapies (PE, CPT, EMDR, CT) to patients with complex presentations without delay. 5, 7
Treat psychiatric comorbidities concurrently with trauma-focused therapy, not sequentially. 6, 1
Emotion dysregulation improves directly through trauma processing by reducing sensitivity and distress to trauma-related stimuli. 5, 7
Common Pitfalls to Avoid
Never assume extensive stabilization is required for dissociation or affect dysregulation—these symptoms improve directly with trauma-focused treatment. 5, 6
Never delay effective treatment based on symptom severity, multiple traumas, or comorbidities—evidence supports immediate trauma-focused intervention. 5, 7
Never use benzodiazepines for PTSD treatment or prevention. 7, 6
Never provide single-session psychological debriefing immediately after trauma. 7, 6