# Post-Traumatic Stress Disorder: Diagnosis and Integrated Treatment

## Diagnosis

### DSM-5-TR Criteria (Adults)

**Criterion A -- Trauma exposure:** direct experience, witnessing, learning about (close family/friend), or repeated/extreme exposure to aversive details (first responders) Qualifying events: combat, sexual assault, physical assault, accidents, natural disasters, childhood abuse/neglect. Does NOT include events experienced only through media (unless work-related) **Criterion B -- Intrusion symptoms (>=1):** intrusive memories, nightmares, flashbacks (dissociative reactions), psychological distress at reminders, physiological reactivity to reminders. **Criterion C -- Avoidance (>=1):** avoidance of trauma-related thoughts/feelings, or avoidance of external reminders (people, places, activities) **Criterion D -- Negative cognitions and mood (>=2):** inability to recall key trauma features, persistent negative beliefs, distorted blame, persistent negative emotional state, diminished interest, detachment, inability to experience positive emotions. **Criterion E -- Arousal and reactivity (>=2):** irritability/aggression, reckless/self-destructive behavior, hypervigilance, exaggerated startle, concentration problems, sleep disturbance. Duration >1 month; causes functional impairment. **Specifiers:** with dissociative symptoms (depersonalization/derealization), with delayed expression (>=6 months post-trauma)

### Differential Diagnosis

Acute stress disorder (symptoms <1 month post-trauma) Adjustment disorder (subthreshold symptoms, non-qualifying stressor) MDD (overlapping symptoms: anhedonia, insomnia, concentration problems) Panic disorder (physiological arousal symptoms overlap) TBI (especially in combat/accident populations -- overlapping cognitive and emotional symptoms) Complex PTSD (ICD-11 entity; discussed in Topic 73)

## Trauma-Focused Psychotherapies

### Cognitive Processing Therapy (CPT)

Developed by Patricia Resick; originally for sexual assault survivors, now broadly applied. Identifies and challenges maladaptive "stuck points" -- beliefs developed as a result of trauma (e.g., "It was my fault," "The world is completely dangerous," "I can never trust anyone") **Protocol:** 12 sessions, individually or in groups. Components: psychoeducation, written impact statement, Socratic questioning of stuck points, worksheets (Challenging Beliefs Worksheet), revised impact statement. Option: CPT with or without written trauma account (CPT-C = cognitive-only version, without written account; shown to be equally effective) Effect sizes: large (d = 1.0-1.5 for PTSD symptom reduction)

### Prolonged Exposure (PE)

Developed by Edna Foa; based on emotional processing theory. **Protocol:** 8-15 sessions (typically 90 minutes each) Components: Psychoeducation about PTSD and treatment rationale. Breathing retraining (relaxation, though not the active ingredient) **In vivo exposure:** graduated approach to avoided real-world situations. **Imaginal exposure:** repeated, detailed recounting of the trauma memory during sessions; recorded and listened to between sessions. Habituation occurs as the patient processes the trauma memory without the expected catastrophic consequences. Effect sizes comparable to CPT.

### Eye Movement Desensitization and Reprocessing (EMDR)

Developed by Francine Shapiro; involves bilateral stimulation (eye movements, tapping, or tones) while processing trauma memories. **8-phase protocol:** history taking, preparation, assessment, desensitization, installation, body scan, closure, reevaluation. Mechanism of action debated: the bilateral stimulation component may not be the active ingredient (the exposure and cognitive processing elements may account for efficacy) Efficacy: comparable to CPT and PE in most head-to-head trials and meta-analyses. May be preferred by patients who find imaginal exposure too distressing (less explicit narrative retelling)

### Choosing Among Trauma-Focused Therapies

| Feature | CPT | Prolonged Exposure (PE) | EMDR |
|---------|-----|------------------------|------|
| Sessions | 12 | 8-15 (90 min each) | 8-12 |
| Core mechanism | Cognitive restructuring of stuck points | Habituation via imaginal + in vivo exposure | Bilateral stimulation during trauma processing |
| Homework | Worksheets, impact statements | Listening to session recordings; in vivo exposure | Minimal |
| Narrative required | Optional (CPT-C without) | Yes (detailed repeated retelling) | Less explicit retelling |
| Effect size | Large (d = 1.0-1.5) | Large (d = 1.0-1.5) | Large (d = 1.0-1.5) |
| Dropout rate | ~20-25% | ~25-30% | ~20-25% |
| Best for | Patients with prominent cognitive distortions | Patients with high avoidance | Patients distressed by explicit narration |

APA, VA/DoD, and NICE guidelines all recommend CPT, PE, and EMDR as first-line treatments. Choice often guided by patient preference, therapist availability, and specific symptom profile. All three have strong evidence; no therapy is clearly superior to the others. Dropout rates: approximately 20-30% across all trauma-focused therapies.

## Pharmacotherapy

### First-Line

**SSRIs:** sertraline and paroxetine are the only FDA-approved medications for PTSD. Response rates: ~60% (vs. ~40% placebo); remission rates: ~20-30%. Pharmacotherapy is generally less effective than trauma-focused psychotherapy for PTSD. Recommended as first-line when psychotherapy is unavailable, patient declines psychotherapy, or as adjunct.

### Second-Line and Augmentation

**Venlafaxine XR:** evidence comparable to SSRIs; not FDA-approved but recommended in VA/DoD guidelines. **Mirtazapine:** some evidence; useful if insomnia and weight loss are prominent. **Atypical antipsychotics:** quetiapine and risperidone for augmentation in partial responders; FDA off-label. **Topiramate:** some evidence for hyperarousal symptoms; not first-line.

### Prazosin for Nightmares -- The Controversy

**Prazosin:** alpha-1 adrenergic antagonist; blocks norepinephrine-mediated activation during sleep. **Initial evidence (Raskind et al. 2003, 2007):** promising RCTs showed significant reduction in trauma-related nightmares and improved sleep in combat veterans. **RASKIND VA Cooperative Study (2018):** large, definitive VA trial failed to show superiority of prazosin over placebo for nightmares in veterans with PTSD. Possible explanations for discrepancy: patient population differences, lower baseline nightmare severity, placebo response rate, dose differences. Current status: some guidelines still recommend prazosin as an option; others have downgraded it; clinical experience suggests benefit in some patients. Pragmatic approach: trial of prazosin remains reasonable for PTSD nightmares when first-line treatments are insufficient; titrate to 6-15 mg at bedtime; monitor for orthostatic hypotension.

### Medications NOT Recommended

Benzodiazepines: no evidence for PTSD; may worsen outcomes (impair fear extinction, increase risk of PTSD development post-trauma) Typical antipsychotics: no evidence. Bupropion: no evidence for PTSD.

## Complex PTSD (Brief Introduction)

ICD-11 entity (not in DSM-5-TR): PTSD + disturbances in self-organization (affect dysregulation, negative self-concept, interpersonal difficulties) Typically associated with prolonged, repeated trauma (childhood abuse, captivity, domestic violence) May require phase-based treatment: stabilization before trauma processing. Full discussion in Topic 73.

<image>
A comparison diagram of the three first-line trauma-focused psychotherapies for PTSD. Three columns for CPT, PE, and EMDR. For each, show: theoretical basis, number of sessions, key therapeutic components (cognitive restructuring for CPT, imaginal/in vivo exposure for PE, bilateral stimulation with trauma processing for EMDR), homework requirements, effect sizes, and dropout rates. Use consistent formatting to facilitate comparison. Include a bottom row showing that all three are equally recommended by major guidelines. Clean clinical reference format.
</image>

<image>
A diagram illustrating the cognitive model underlying CPT for PTSD. Show how a traumatic event leads to natural emotional reactions (fear, horror) AND to maladaptive "stuck points" (assimilation: "It was my fault" or over-accommodation: "The world is always dangerous, no one can be trusted"). Show how stuck points maintain PTSD symptoms. Then show the CPT intervention: Socratic questioning and worksheets challenge stuck points, leading to more balanced beliefs and symptom reduction. Include examples of common stuck points in safety, trust, power/control, esteem, and intimacy themes. Clinical education style.
</image>

<image>
A treatment algorithm for PTSD. Start with "PTSD diagnosed." First-line: trauma-focused psychotherapy (CPT, PE, or EMDR) with or without pharmacotherapy (SSRI). If psychotherapy unavailable or declined: SSRI monotherapy (sertraline or paroxetine). For partial response: augment with prazosin for nightmares (noting controversy), atypical antipsychotic for persistent symptoms. For treatment-resistant: combine modalities, consider intensive outpatient programs. Include a warning box: "Do NOT prescribe benzodiazepines for PTSD." Show assessment points using PCL-5. Color-coded flowchart.
</image>

## Clinical Pearls

Trauma-focused psychotherapy (CPT, PE, or EMDR) is the most effective treatment for PTSD -- pharmacotherapy alone produces modest response rates. Benzodiazepines are contraindicated in PTSD -- they do not treat the disorder and may impair fear extinction learning that is necessary for recovery. SSRIs are first-line pharmacotherapy, but response rates (~60%) and remission rates (~25%) are modest compared to psychotherapy. The prazosin-for-nightmares evidence is mixed after the negative 2018 VA Cooperative Study -- a pragmatic trial remains reasonable, but it is no longer a slam-dunk recommendation. Screen for PTSD in all patients with depression, anxiety, substance use, and chronic pain -- PTSD is commonly comorbid and frequently missed. CPT can be delivered without a written trauma account (CPT-C) with equivalent efficacy -- this may reduce dropout for patients who find narrating the trauma too distressing. Avoidance is the engine that maintains PTSD -- treatment must ultimately address avoidance through exposure or cognitive processing.

## References

- Resick PA, et al. A randomized clinical trial to dismantle components of cognitive processing therapy for posttraumatic stress disorder in female victims of interpersonal violence. *J Consult Clin Psychol*. 2008;76(2):243-258.
- Foa EB, et al. *Prolonged Exposure Therapy for PTSD: Emotional Processing of Traumatic Experiences, Therapist Guide*. 2nd ed. Oxford University Press; 2019.
- Raskind MA, et al. Trial of prazosin for post-traumatic stress disorder in military veterans. *N Engl J Med*. 2018;378(6):507-517.
- VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder. Version 3.0. 2023.
- Shapiro F. *Eye Movement Desensitization and Reprocessing: Basic Principles, Protocols, and Procedures*. 3rd ed. Guilford Press; 2018.