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

Treatment of Post-Traumatic Stress Disorder

Trauma-focused psychotherapy must be initiated immediately as first-line treatment for PTSD, with Prolonged Exposure (PE), Cognitive Processing Therapy (CPT), or Eye Movement Desensitization and Reprocessing (EMDR) showing 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 manualized trauma-focused psychotherapies as the primary intervention 1, 2:

• Prolonged Exposure (PE) involves imaginal exposure (repeated recounting of traumatic memories) and in vivo exposure (confrontation with trauma-related situations and objects), demonstrating the strongest evidence base 1, 2

• Cognitive Processing Therapy (CPT) teaches patients to identify and challenge trauma-related irrational beliefs through evidence-based cognitive restructuring, with equivalent efficacy to PE 1, 2

• Eye Movement Desensitization and Reprocessing (EMDR) provides comparable outcomes to PE and CPT 1, 2, 3

These therapies address the root cause of PTSD and provide more durable benefits than medication, with relapse rates substantially lower after completing psychotherapy compared to medication discontinuation (26-52% relapse with medication cessation versus lower rates after CBT completion) 1, 2

Critical Treatment Principle: No Stabilization Phase Required

Do not delay trauma-focused therapy with prolonged "stabilization phases"—patients with complex presentations including multiple traumas, severe comorbidities, dissociation, substance use history, and suicidal ideation benefit from immediate trauma processing. 1, 2

• No randomized controlled trials demonstrate that patients with complex PTSD require or benefit from prolonged stabilization before trauma processing 2

• Emotion dysregulation, dissociative symptoms, and negative self-concept improve directly through trauma processing itself, without requiring separate stabilization interventions 1, 2

• Patients with severe comorbidities including schizophrenia, psychotic disorders, and major depression benefit from trauma-focused treatment without evidence of iatrogenic effects 4

Pharmacotherapy: Adjunctive Role Only

Add pharmacotherapy only when psychotherapy is unavailable, patient refuses therapy, or residual symptoms persist after completing psychotherapy 1, 2:

• First-line medications are SSRIs: sertraline, paroxetine, or fluoxetine, and the SNRI venlafaxine, showing 53-85% treatment response rates 1, 5, 6

• Sertraline dosing: Initiate 25-50 mg daily, titrate to maximum 200 mg/day as needed 1, 7

• Paroxetine dosing: 20-40 mg/day demonstrated superiority over placebo, with no clear additional benefit for doses higher than 20 mg/day 8

• Continue treatment for minimum 6-12 months after symptom remission due to high relapse rates (26-52%) upon discontinuation 1, 2, 7

Treatment of PTSD-Related Sleep Disturbance

Prazosin is specifically recommended for PTSD-related nightmares (Level A evidence) 1, 2, 5:

• Start 1 mg at bedtime, increase 1-2 mg every few days to average effective dose of 3 mg (range 1-13 mg) 1, 2

• Monitor for orthostatic hypotension 1

• Consider testing for obstructive sleep apnea, as many patients with PTSD-related sleep disturbance have this comorbid condition 5

Medications to AVOID Completely

Never use benzodiazepines for PTSD treatment—evidence demonstrates 63% of PTSD patients receiving benzodiazepines developed chronic PTSD at 6 months compared to only 23% receiving placebo, indicating benzodiazepines actively worsen PTSD outcomes 1, 4, 2

• If patients are currently on benzodiazepines, gradual dose reduction is essential to prevent withdrawal seizures, increased anxiety, depression, and altered mental status 1

• Refer to addiction medicine or psychiatry specialists for supervised tapering, particularly those with co-occurring chronic pain, alcohol abuse, or unstable psychiatric conditions 1

Never use psychological debriefing (single-session intervention within 24-72 hours post-trauma)—it significantly worsens outcomes with 26% PTSD prevalence in debriefed patients versus 9% in controls 1, 4, 2

Treatment Algorithm

1. Initiate trauma-focused psychotherapy immediately (PE, CPT, or EMDR) without delay, even in complex presentations 1, 2

2. Add or substitute pharmacotherapy if psychotherapy is unavailable, ineffective, or patient preference strongly favors medication 1, 2

3. For persistent nightmares, add prazosin regardless of whether patient is receiving psychotherapy or medication 1, 2

4. Continue acute treatment for 9-15 sessions of trauma-focused psychotherapy 2

5. Maintain pharmacotherapy for 6-12 months minimum after symptom remission if medication was used 1, 2

Managing Comorbid Conditions

When depression and anxiety co-occur with PTSD, prioritize treating PTSD with trauma-focused therapy—depression symptoms generally improve following trauma processing 1, 4:

• SSRIs effectively treat both PTSD and comorbid depression/anxiety simultaneously 1

• Treatment response is unrelated to baseline depression severity 1

• Psychiatric comorbidities, particularly mood disorders and substance use, are best treated concurrently 5

Access to Care Considerations

• Trauma-focused psychotherapy may be limited to large cities and medical schools, while medication is more widely available 4

• Video or computerized interventions produce similar effect sizes to in-person treatment and may improve access 4

• Secure video teleconferencing can effectively deliver recommended psychotherapy when in-person options are unavailable 4