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

Treatment of PTSD

Trauma-focused psychotherapy—specifically Prolonged Exposure (PE), Cognitive Processing Therapy (CPT), or Eye Movement Desensitization and Reprocessing (EMDR)—should be initiated immediately as first-line treatment, with 40-87% of patients no longer meeting PTSD criteria after 9-15 sessions. 1, 2

First-Line Treatment: Trauma-Focused Psychotherapy

The 2023 VA/DoD Clinical Practice Guideline strongly recommends three specific trauma-focused psychotherapies as the primary intervention 1, 2:

• Prolonged Exposure (PE): Demonstrates the highest success rates, with 40-87% of patients achieving remission after 9-15 sessions 1, 2
• Cognitive Processing Therapy (CPT): Equally effective as PE, particularly addresses negative trauma-related appraisals that fuel emotion dysregulation 2
• Eye Movement Desensitization and Reprocessing (EMDR): Provides comparable outcomes to PE and CPT 2, 3

These therapies should be started immediately without requiring a stabilization phase, even in patients with complex presentations including multiple traumas, severe comorbidities, dissociation, or emotion dysregulation 1, 4. The traditional phase-based approach requiring prolonged stabilization before trauma processing lacks empirical support and may inadvertently delay effective treatment 4.

Individual therapy has stronger evidence than group therapy and should be the preferred format 1. Video or computerized interventions produce similar effect sizes to in-person treatment and can improve access when in-person therapy is unavailable 1.

Second-Line Treatment: Pharmacotherapy

Medication should be considered when psychotherapy is unavailable, ineffective, the patient refuses psychotherapy, or residual symptoms persist after psychotherapy 1, 2.

FDA-Approved First-Line Medications

Sertraline and paroxetine are the only FDA-approved medications for PTSD 5, 6:

• Sertraline: Start 50 mg daily, can increase to 50-200 mg/day 5
• Paroxetine: Start 20 mg daily, can increase to 20-50 mg/day; doses of 20 mg and 40 mg both demonstrated superiority over placebo 6, 7
• Venlafaxine: Also recommended as first-line despite lacking FDA approval, dosed 32.5-300 mg/day 1, 7

The effect size for SSRIs is small (standardized mean difference -0.28) but statistically significant 7. Critically, relapse rates after medication discontinuation are high (26-52%) compared to only 5-16% for patients maintained on medication, and substantially higher than relapse rates after completing trauma-focused psychotherapy 1, 2. Continue medication for at least 6-12 months after symptom remission before considering discontinuation 1.

Medications for Specific Symptoms

For PTSD-related nightmares: Prazosin is strongly recommended with Level A evidence 1, 2:

• Start 1 mg at bedtime
• Increase 1-2 mg every few days
• Average effective dose 3 mg (range 1-13 mg)
• Monitor for orthostatic hypotension 1

For sleep disturbances: Trazodone 25-600 mg may be considered, though 60% experience side effects including daytime sedation 1

Critical Medications to AVOID

Benzodiazepines (including alprazolam and clonazepam) are strongly contraindicated in PTSD treatment 1, 2. Evidence shows 63% of patients receiving benzodiazepines developed PTSD at 6 months compared to only 23% receiving placebo 1, 8. They worsen PTSD outcomes and should be avoided entirely 1.

Psychological debriefing (single-session intervention within 24-72 hours post-trauma) should never be used, as randomized controlled trials show it may be harmful 1, 2.

Treatment Algorithm

1. Initiate trauma-focused psychotherapy immediately (PE, CPT, or EMDR) without delay 1, 2, 4
2. Add or substitute pharmacotherapy if psychotherapy is unavailable, ineffective, or strongly preferred by patient 1, 2
3. Start with sertraline 50 mg or paroxetine 20 mg daily 5, 6, 7
4. Add prazosin if nightmares persist despite adequate SSRI dosing 1, 2
5. Continue medication 6-12 months minimum after symptom remission 1

Common Pitfalls to Avoid

Do not delay trauma-focused treatment by labeling patients as "too complex"—this assumption lacks empirical support and restricts access to effective interventions 2, 4. Emotion dysregulation, dissociative symptoms, and self-loathing improve directly through trauma processing itself, without requiring separate stabilization interventions 1, 4.

Do not assume extensive stabilization is required for patients with severe comorbidities, multiple traumas, or emotion dysregulation—these symptoms improve with trauma-focused treatment 4, 8. The only exceptions requiring stabilization first are acute suicidality requiring hospitalization, active substance dependence requiring detoxification, or current psychotic symptoms requiring stabilization 4.

Do not prescribe benzodiazepines even for anxiety or insomnia in PTSD patients, as they worsen long-term outcomes 1, 8.

Treatment Duration and Outcomes

Acute treatment typically consists of 9-15 sessions of trauma-focused psychotherapy 1, 2. With appropriate treatment, 40-87% of patients no longer meet PTSD criteria after completing trauma-focused psychotherapy 1, 2. Relapse rates are significantly lower after completing CBT compared to medication discontinuation 1.

Many PTSD patients prefer psychotherapy to medication when given a choice 1. Psychotherapy provides more durable benefits than medication, with lower relapse rates after treatment completion 2, 4.