What is the first line treatment for a patient with post-traumatic stress disorder (PTSD) and no significant medical history?

First-Line Treatment for Post-Traumatic Stress Disorder

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

Primary Treatment Recommendation

Initiate trauma-focused psychotherapy immediately without requiring a stabilization phase, even in patients with complex presentations including multiple traumas, severe comorbidities, or emotion dysregulation. 1, 2

The VA/DoD Clinical Practice Guideline strongly recommends three specific manualized trauma-focused psychotherapies over all other interventions: 1

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

Critical Paradigm Shift: No Stabilization Required

Do not delay trauma-focused treatment by requiring a prolonged stabilization phase. 1 This traditional phase-based approach lacks empirical support and communicates to patients that they are incapable of processing traumatic memories. 2

• Emotion dysregulation, dissociative symptoms, and self-loathing improve directly through trauma processing itself, without requiring separate stabilization interventions 1, 2
• No randomized controlled trials demonstrate that patients with complex PTSD require or benefit from prolonged stabilization before trauma processing 1
• History of childhood sexual abuse, multiple traumas, severe comorbidities, and even nonacute suicidal ideation do not negatively affect treatment response 3

Pharmacotherapy: Second-Line Treatment

Consider medication only when psychotherapy is unavailable, ineffective, the patient refuses psychotherapy, or residual symptoms persist after psychotherapy. 1

First-Line Medications (FDA-Approved)

Sertraline and paroxetine are FDA-approved for PTSD and represent first-line pharmacotherapy options. 1, 4, 5

• Sertraline: Start 50 mg daily, titrate to 50-200 mg/day as needed 4
• Paroxetine: Start 20 mg daily, may increase to 20-50 mg/day 5
• Venlafaxine: Alternative SNRI option if SSRIs not tolerated, dosed 32.5-300 mg/day 1, 3

Critical Medication Duration

Continue SSRI treatment for 6-12 months minimum after symptom remission. 3 Discontinuation leads to high relapse rates of 26-52% when shifted to placebo, compared to only 5-16% maintained on medication. 1, 3

Relapse rates after completing trauma-focused psychotherapy are substantially lower than after medication discontinuation, further supporting psychotherapy as first-line treatment. 1, 3

Medications to AVOID

Never prescribe benzodiazepines for PTSD treatment. 1, 3 Evidence shows 63% of patients receiving benzodiazepines developed PTSD at 6 months compared to only 23% receiving placebo. 1, 3, 2

Do not use psychological debriefing (single-session intervention within 24-72 hours post-trauma), as randomized controlled trials show it may be harmful. 1, 3

Treatment Algorithm

1. Immediately initiate trauma-focused psychotherapy (PE, CPT, or EMDR) without delay, even in complex presentations 1, 3
2. Add or substitute pharmacotherapy if psychotherapy is unavailable, ineffective, or patient preference strongly favors medication 1
3. For PTSD-related nightmares specifically: Add prazosin 1 mg at bedtime, titrate to average effective dose of 3 mg (range 1-13 mg) 1, 3
4. Continue treatment for 9-15 sessions of trauma-focused psychotherapy for adequate dose 1
5. If using medication, maintain for 6-12 months minimum after symptom remission before considering discontinuation 3

Common Pitfalls to Avoid

• Labeling patients as "too complex" for trauma-focused therapy: This assumption lacks empirical support and restricts access to effective interventions 1
• Requiring prolonged stabilization before trauma processing: Delays effective treatment and may reduce patient motivation 1, 2
• Prescribing benzodiazepines for anxiety symptoms: Worsens PTSD outcomes and may promote disorder development 1, 3, 2
• Discontinuing medication prematurely: Leads to high relapse rates; maintain for 6-12 months minimum 3

Treatment Accessibility Considerations

When in-person trauma-focused psychotherapy is unavailable, video or computerized interventions produce similar effect sizes and should be utilized. 3 Secure video teleconferencing can effectively deliver recommended psychotherapy when validated for this modality. 3