Initial Trauma-Informed Psychiatric Assessment for a 36-Year-Old Woman with Childhood Sexual Assault History and Complex PTSD Symptoms
Initiate trauma-focused cognitive-behavioral therapy (TF-CBT), prolonged exposure, cognitive processing therapy, or EMDR immediately without requiring a prolonged stabilization phase, as these evidence-based therapies achieve 40–87% remission rates for PTSD after 9–15 sessions and directly address panic symptoms, hypervigilance, and avoidance behaviors underlying her presentation. 1, 2
Immediate Safety Assessment and Triage
Conduct a thorough safety assessment screening for suicidal ideation, self-harm behaviors, and confirm she is in a physically safe environment away from any current perpetrators or threats. 1
Assess for acute risk of harm including whether she is experiencing active thoughts of self-harm, has access to means, and whether her living situation is secure. This is the first priority before proceeding with further assessment. 3
Screen for ongoing abuse or exploitation by asking directly: "Are you currently safe where you are living?" and "Is anyone hurting you or making you feel unsafe now?" 3
Trauma-Informed Assessment Approach
Environmental Modifications for This First Session
Acknowledge her extreme anxiety about the new setting by explicitly stating: "I understand new places and people can feel overwhelming. You are safe here, and you can leave at any time." Address her fear of being trapped directly. 3, 4
Position yourself near the door so she has a clear exit path, never blocking her access to leave. Ask: "Where would you feel most comfortable sitting?" to give her control over positioning. 4
Explain every step before it happens: "I'm going to ask you some questions about your symptoms. You can decline to answer anything, and we can take breaks whenever you need." This predictability reduces hypervigilance. 3, 4
Avoid any physical examination today given her extreme avoidance of medical touch and the protective behavior of wearing three pairs of pants. Physical exams can be deferred and addressed later with extensive preparation. 4
Structured PTSD and Symptom Screening
Use the PTSD Reaction Index Brief Form or similar validated PTSD screening tool to quantify symptom severity across re-experiencing, avoidance, negative cognitions/mood, and hyperarousal domains. 3
Screen for depression using PHQ-9 as comorbid depression is extremely common in CSA survivors and affects treatment planning. 3, 1
Assess specific trauma-related triggers by asking: "What situations, places, or sensations make you feel most unsafe or panicked?" Document her cleithrophobia (fear of being trapped), avoidance of gynecological care, and hypervigilance to novelty. 3
Evaluate dissociative symptoms by asking: "Do you ever feel disconnected from your body or like you're watching yourself from outside?" as dissociation is common in CSA survivors. 2
Screen for substance use as a maladaptive coping mechanism: "Do you use alcohol, medications, or other substances to help manage your anxiety or memories?" 1
Psychoeducation and Immediate Psychological First Aid
Normalize her symptoms by explaining: "Your body and mind learned to protect you during the abuse by staying on high alert. These reactions—the anxiety, the fear of being trapped, the avoidance—are your brain's way of trying to keep you safe, even though the danger has passed." 3, 1
Teach one grounding technique today: Implement breathing retraining (e.g., 4-7-8 breathing: inhale 4 seconds, hold 7 seconds, exhale 8 seconds) or the 5-4-3-2-1 sensory grounding technique to manage acute panic symptoms. 1
Provide written information about PTSD symptoms and treatment options, as patients in high distress often cannot retain verbal information. 5
Treatment Plan: Psychotherapy as Primary Intervention
Immediate Trauma-Focused Therapy Referral
Arrange a "warm handoff" to a trauma-specialized therapist within 1 week—meaning you directly introduce her (by phone or in person) to the therapist rather than simply providing a referral number. This dramatically increases follow-through. 1
Do NOT delay trauma processing by requiring months of "stabilization" first. Current evidence demonstrates that trauma-focused therapy should begin immediately, even in patients with severe anxiety, hypervigilance, and avoidance. Delaying treatment is iatrogenic and reduces self-confidence and motivation. 1, 2
Specify evidence-based modalities: Prolonged Exposure (PE), Cognitive Processing Therapy (CPT), or Eye Movement Desensitization and Reprocessing (EMDR) are equally effective. If she cannot tolerate exposure-based work initially, CPT or EMDR are valid alternatives. 1, 2, 6
Set expectation for 9–15 sessions of weekly trauma-focused therapy, explaining that most patients experience significant symptom reduction within this timeframe. 1, 2
Pharmacotherapy Considerations
Critical Medication Avoidance
- Do NOT prescribe benzodiazepines (alprazolam, clonazepam, lorazepam) for her anxiety or panic symptoms. Evidence shows 63% of patients receiving benzodiazepines after trauma develop PTSD at 6 months compared to only 23% with placebo—they triple the risk of chronic PTSD. 1, 2
SSRI Initiation if Indicated
Consider starting an SSRI (sertraline 25–50 mg daily or paroxetine 10–20 mg daily) if her panic symptoms are moderate-to-severe and impairing daily function. SSRIs demonstrate 53–85% response rates in panic disorder and PTSD. 1, 2, 6
Frame medication as adjunctive, not primary treatment: "This medication can help reduce the intensity of your panic and anxiety while you do the therapy work that addresses the root cause." 1, 2
Plan for 9–12 months of SSRI treatment after symptom remission to prevent relapse, as discontinuation leads to 26–52% relapse rates. 2
Sleep Management Without Benzodiazepines
- If insomnia is prominent, consider prazosin 1 mg at bedtime (titrate by 1–2 mg every few days to average effective dose of 3 mg) specifically for trauma-related nightmares, or trazodone 25–50 mg at bedtime for sleep initiation. 2
Safety Planning for Avoidance Behaviors
Address gynecological care avoidance by documenting this as a trauma-related barrier and planning future trauma-informed pelvic exams only after she has made progress in therapy. When the time comes, arrange for: 5, 4
- A female provider she has met beforehand
- Explicit verbal consent at each step
- Her ability to stop the exam at any point
- A support person present if she wishes
- Sedation options if needed
Create a written safety plan for panic attacks that includes: 1
- Early warning signs (e.g., "I start feeling trapped or my heart races")
- Grounding techniques learned today
- Trusted person to call (name and number)
- Crisis hotline: 988 Suicide & Crisis Lifeline
- Emergency department if she feels unsafe
Follow-Up and Monitoring
Schedule follow-up within 1–2 weeks to assess medication response (if prescribed), confirm she has started trauma-focused therapy, and evaluate safety. 1, 5
Monitor for treatment engagement: If she does not attend the first therapy session, contact her proactively to problem-solve barriers (transportation, cost, fear). 1
Reassess PTSD symptoms at 6–8 weeks using the same screening tool to quantify treatment response. 3, 1
Watch for secondary traumatic stress in yourself as a provider hearing detailed CSA disclosures. Debrief with colleagues and practice self-care to prevent burnout. 3
Critical Pitfalls to Avoid
Do not label her as "too complex" or "not ready" for trauma-focused therapy due to her severe avoidance and anxiety. This labeling has iatrogenic effects and delays effective treatment. 1, 2
Do not require an extended stabilization period before trauma processing. Evidence does not support delaying trauma-focused work, even in patients with hypervigilance, dissociation, or severe avoidance. 1, 2
Do not use psychological debriefing (single-session detailed recounting of trauma within 24–72 hours post-disclosure) as it lacks evidence and may be harmful. 1, 2
Do not minimize her protective behaviors (wearing three pairs of pants) as "irrational"—these are adaptive responses to overwhelming fear and should be respected while gently working toward reducing avoidance through therapy. 3, 4
Do not conduct a physical exam today or push for gynecological care referral at this first visit. Her avoidance is a core PTSD symptom that will improve with trauma-focused therapy. 4
Documentation and Coordination
Document using trauma-informed language: Avoid terms like "noncompliant" or "resistant." Instead: "Patient demonstrates adaptive avoidance behaviors related to trauma history." 3, 7
Obtain her consent before sharing information with other providers, explaining exactly what will be shared and why. Respect her autonomy and control over her medical information. 5
Coordinate with the trauma therapist (with her permission) to ensure integrated care, particularly regarding medication management and crisis planning. 1